Health Care for All: A Framework for Moving to a Primary Care-Based Health Care System in the United States

Goal

To ensure access to health care for everyone in the United States through a foundation of comprehensive and longitudinal primary care.

The intent of this policy document is to give the American Academy of Family Physicians (AAFP) and its Board of Directors the needed advocacy flexibility to consider all options that might come before federal and state governments and the American people in working to achieve the goal of access to health care for all – a goal based upon AAFP policy which recognizes that health is a basic human right for every person and that the right to health includes universal access to timely, acceptable and affordable health care of appropriate quality.

Introduction

The health care system in the United States is uncoordinated and fragmented and emphasizes intervention rather than prevention and comprehensive health management. Health care costs continue to increase at an unsustainable rate and quality is far from ideal.i,ii The U.S. spends nearly 18 percent of GDP on health care, yet Americns die younger and are less healthy than residents of other high-income countries. The U.S. has the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, the hightes maternal and infant mortality, and among the highest suicide rates.iii

Over the past two decades, policies implemented through the Children’s Health Insurance Program (CHIP) and the Patient Protection and Affordable Care Act (ACA) have extended access to affordable health care coverage to millions of previously uninsured, non-Medicare eligible adults and children. The uninsured population reached a historic low of 7.9% in 2023 under the implementation of these policies.iv The greatest gains in coverage have occurred among our most vulnerable populations and young adults. The progress made is at risk, however, if federal and state changes to insurance coverage, eligibility, enrollment, and financing weaken the protections put in place by CHIP and ACA. The AAFP recognizes health as a basic human right for every person and has strongly advocated to maintain and expand on these health care coverage programs to ensure that all Americans, regardless of social, economic status, race, religion, gender or sexual orientation have the right to universal access to timely, high quality, and affordable essential health care services.

Ensuring that all people in the United States have access to affordable health care that provides a defined set of essential health benefits (EHB) is necessary in order to move toward a healthier and more productive society. Additionally, our health care system must begin to account for and address social determinants that have a profound impact on individual and population health outcomes and costs, such as socioeconomic status, housing and occupational conditions, food security, and the environment. As noted by the Commonwealth Fund, the design of a system to provide health care coverage to all people “will have a deep impact on its ability to make sustainable and systematic improvements in access to care, equity, quality of care, efficiency, and cost control.”v

Efforts to improve health care delivery require strengthening and expanding the primary care workforce as well as to simplify and streamline how that care is financed. Effective health system finance and payment reform must emphasize primary care, expand its infrastructure, and redesign payment methods to reward clinicians for taking on medically and social complexity as well as expanding services such as integration with behavioral health, care management and clinical pharmacists. Rewarding the achievement of narrow metrics, or number of patients seen in a given time frame, is a more accurate measurement of the socioeconomic makeup of a patient population and not the skill set of the clinician. Research shows that focusing on specialty care leads to fragmentation, variable quality, and increased costs. Transformative changes in financing and delivery can improve primary care operations, making them more accessible, promoting prevention, supporting chronic illness management, and engaging patients in self-management, which enhances health care quality and cost efficiency.vi As stated previously, despite the U.S. spending the most on health care per capita and as a percentage of GDP, investments in primary care have not kept up and consequently, a third of U.S. adults lack a usual source of care, with this number increasing annually.vii

Family medicine and primary care are the only entities charged with longitudinal continuity of care for the whole patient, family and community. The patient and primary care physician relationship and its comprehensiveness have the greatest effect on health care outcomes and costs over the long term. However, the current United States health care system fails to deliver comprehensive primary care because of the way primary care has been, and is currently, financed.

The U.S. payment system favors more procedural services than the comprehensive care of patients, leading to undervaluation of and under investment in primary care. Spending on primary care was less than 5% of total health care spending in 2022 and continues to decline across all payers.viii In 2022, payment to primary care physicians per visit averaged $259, compared to $1,092 for gastroenterology. This relative lack of revenue limits practice capacity to provide high-quality primary care and – in addition to other principal factors such as growing administrative burden and medical school debt – hinders the field’s ability to draw in new clinicians.

According to the Center for Evaluative Clinical Sciences at Dartmouth (now called the Dartmouth Institute for Health Policy and Clinical Practice), U.S. states that rely more on primary care have lower Medicare spending (inpatient reimbursements and Part B payments); lower resource inputs (hospital beds, intensive care unit [ICU] beds, total physician labor, primary care labor, and medical specialist labor); lower utilization rates (physician visits, days in the ICU, days in the hospital, and patients seeing 10 or more physicians); and better quality of care (fewer ICU deaths and a higher composite quality score).ix

Fundamental changes are necessary to realign the delivery and financing of health care in the United States to a system where reimbursements prioritize comprehensive primary care. Achieving the Organization for Economic Cooperation and Development (OECD) average of 12-15% investment in primary care requires doubling current allocations and deploying new resources. Payment policies across all payers must align and shift to increase primary care reimbursement and funding, while public policy and workforce strategies dramatically expand medical education and graduate training to ensure a more robust cadre of family physicians, which are integral to effective health care delivery teams. Equally critical is the reduction of unnecessary administrative burdens and costs, which hinder efficiency and accessibility. Legislative action at federal and state levels must holistically address these issues to fulfill the Quintuple Aim—better care, improved health, smarter spending, and health equity, and strengthening physician well-being and work place satisfaction. Timely studies, such as Basu et al. (2019) on primary care investment impacts and Friedberg et al. (2015) on administrative burden reduction, provide critical insights for advancing these reforms. (NASEM 2019)x,xi,xii

Key Elements of the Framework

• Everyone will have access to affordable health care providing equal access to age-appropriate and evidence-based health care services.
• Everyone will have a primary care physician and a usual source of primary care or "medical home".
• Insurance reforms that have established consumer protections and nondiscriminatory policies will remain and will be required of any proposal or option being considered to achieve access to health care for all. Those reforms and protections include, but are not limited to, continuation of guaranteed issue; prohibitions on insurance underwriting that uses health status, age, gender, or socioeconomic criteria; prohibitions on annual and/or lifetime caps on benefits and coverage; required coverage of defined EHB; and required coverage of designated preventive services and vaccines without patient cost sharing.
• Any proposal will reflect at least a doubling of the percentage of health care spending invested in primary care.^xiii This increased primary care spend must result in payment that supports and sustains advanced primary care and reduces the current payment disparity between primary care and subspecialty care to ensure an adequate primary care physician workforce.
  
• Federal, state, and private funding for graduate medical education (GME) will be reformed to establish and achieve a national physician workforce policy that produces a primary care physician workforce sufficient to meet the nation’s health care needs. GME payments will correct for historical maldistribution by ensuring new positions are allocated to mitigate rural/urban and other geographic and specialty imbalances and workforce shortages.  GME payments need to support training/learning with an ambulatory clinical team supporting the person/patient and physician, and scribing support to train new FM physicians in efficient team-based care, which will also increase the resident’s physician scope learning. Additionally, U.S. medical schools will be held to a higher standard in regard to producing the nation’s needed primary care physician workforce.
• Essential primary care visits and services provided by a to a primary care physician and/or members of the care team will not be subject to excessive cost-sharing.
• In any system of universal coverage, the ability of patients and physicians to voluntarily enter into direct contracts for a defined or negotiated set of services (e.g., direct primary care [DPC] by individuals or direct contracting by employers) will be preserved. Additionally, individuals will always be allowed to purchase additional or supplemental private health insurance.
• Widespread administrative simplification in health care is necessary to achieve high quality access to care for all. This includes drastic improvements to strengthen the electronic exchange of data and removing unnecessary burdens throughout the compliance, claims and billing processes.
• Any proposal will address the lack of standardization across electronic health record platforms that burden primary care physicians and inhibits effective information sharing and care coordination across the patient’s care team. Without advancements to interoperability and data sharing standards, primary care physicians will continue to face obstacles in sharing information with their patients and other members of their patients’ care team.

To achieve accessible health care for all, the AAFP supports bipartisan solutions that follow the above referenced principles, are supported by a majority of the American people, and involve one or more of the following approaches, with the understanding that each of these have their strengths and challenges:

Preferred approaches

• A public option with a Bismarck approach is a form of statutory health insurance involving multiple nonprofit payers that are required to cover a government-defined benefits package and to cover all legal residents. Physicians and other clinicians operate independently in a mix of public and private arrangements. The public option would be an administered plan directly competing for customers with private insurance plans could be national or regional in scope. Physicians and other clinicians would continue to operate independently.

• A single-payer model approach that is clearly defined in its organization, financing, and model of delivery of health care services would be publicly financed and publicly or privately administered, with the government collecting and providing the funding to pay for health care provided by physicians and other clinicians who work independently or in private health systems.

As noted in the AAFP's Discussion Paper on Health Care Coverage and Financing Models, which was commissioned by the AAFP Board of Directors in 2017, each of these options for achieving health care coverage for all has its strengths and challenges, which need and deserve to be debated by the American people and their elected officials and representatives. These include, but are not limited to, the following important issues:

• Level of administrative and regulatory burden for physicians, clinicians and other health care providers, and patients/consumers
• Impact on overall health care costs to government, employers, and individuals
• Level of patient, consumer, physician, and clinician satisfaction
• Level of tax burden
• Impact on the timely delivery of health care services (wait times) and delays in scheduling elective health care services
• Clarity of the financing model and levels of payment to physicians, clinicians, and other health care providers
• Inclusion of family physicians on payment, delivery, and other health care decision-making boards
• A description of and clarity on a core set of essential health care benefits available to all, especially primary and preventive care, management of chronic illnesses, and protections from catastrophic health care expenses
• Impact on the equitable availability and delivery of health care services
• Impact on quality and access
• Determination of whether there are global budgets for inpatient and long-term care facilities and price/payment negotiations for outpatient care

Comprehensive Primary Care

Advanced primary care embodies the principle that patient-centered primary care is comprehensive, continuous, coordinated, connected, and accessible for the patient’s first contact with the health system. APC aims to improve clinical quality through the delivery of coordinated, longitudinal care that improves patient outcomes and reduces health care spending. The AAFP believes these benefits of APC are best achieved when individuals have a clearly identified usual souce of primary care with a physician supported by an APC practice. This is consistent with the goals of the Joint Principles of the Patient-Centered Medical Home. The key functions of a primary care medical home are:

1. Access and Continuity
2. Planned Care and Population Health
3. Care Management
4. Connection to Community Support Service
5. Allied Health Servces/Coordinated Care
6. Behavioral Health
7. Nutrition & Diabetes Education
8. Substance Use Disorder
9. Clinical Pharmacists
10. Physician Therapy, Occupational Therapy, Speech Therapy and Applied Behavioral Analysis

Benefits

All proposals or options to provide access to health care for all will be required to cover a defined set of essential health benefits. At a minimum, these would include items and services in the following benefit categories:

1. Ambulatory patient services
2. Annual wellness visits
3. Chronic disease management
4. Acute Care Service
5. Emergency and urgent care
6. Inpatient care
7. Obstetrical and newborn care
8. Mental aqnd behavioral health services, including substance use disorder services
9. Prescription drugs, durable medical equipment and immunizations and office therapies and procedures
10. Rehabilitative and habilitative services
11. Laboratory services, other types of diagnostic tests, and radiographs
12. Preventive and wellness services and chronic disease management
13. Pediatric services
14. Dental, vision and hearing care

In addition to requiring coverage for EHB, all proposals or options will ensure that primary care is provided through the patient’s primary care medical home. To foster a longitudinal relationship with a primary care physician, all proposals or options will provide the services listed above independent of financial barriers (i.e., deductibles and co-pays) if the services are provided by the patient’s designated primary care physician.

Affordability

To achieve the goal proposed in this paper: “to ensure health care coverage for everyone in the United States through a foundation of comprehensive and longitudinal primary care,” it will not be sufficient to focus on access to health care and primary care alone.  There will need to be an effort aimed at identifying and reducing the costs of health care services including the administrative costs of delivering those services.

A health care system that is comprehensive and prioritizes primary care must also emphasize the cost and affordability of care. This is important not only for consumers, but also for the decision-making of physicians, clinicians, payers, and government agencies. Affordability is a critical component in efforts to reform the United States health care system.

• Prevention & Public Health – there should be increased investment in preventive care, specifically those preventive services that have been proven to reduce the prevalence of preventable diseases (e.g., access to free vaccines and screening programs).  A focus on reducing preventable diseases likely would reduce or, at minimum defer, future high-cost spending for preventable diseases.  In addition, there should be an increased focus on identifying societal and environmental factors that contribute to increased health care spending.

• Transparency – an increased investment in primary care and the medical home allows health plans to not only reduce the costs of treating high-risk patients but improve the quality of health services.^xi This increased investment should be supported by aggressive efforts to establish price transparency for all health care services.  Such transparency likely will contribute to reducing excessively high health care costs by informing the public about their costs of care and creating more competition in the health care industry.  

• Site-Neutral Payment Policies – for many health care services, payment is often highly variable depending on the site of service (payment higher for the same service performed in a hospital versus an ambulatory surgery center versus a physician’s office) despite no significant differences in quality or outcomes of care. Such payment policies contribute to excessive spending in our current system. In addition, these policies incentivize consolidation, decrease competition between providers of care, and facilitate over-utilization of high-cost health care services.  This issue could be addressed effectively through site-neutral payment policies and the elimination of some facility fees.

• Administrative Costs – a significant share of U.S. health care costs is due to high administrative costs, including billing complexities which are exasperated by multiple payers. A 2024 American Medical Association survey to physicians found that prior authorization adds significant costs to the entire health care system. For example, patients are often forced to try ineffective treatments and/or schedule additional office visits because of PA requirements and delays. These delays inevitably lead patients to seek more expensive forms of care, including emergency room visits, and can even lead to unexpected hospitalization^xv. Countries with lump-sum budgets and fewer health care payers have seen lower costs in administrative spending.^xvi Additionally, no link has been found between higher administrative costs and higher quality care.

 In addition to billing and coding administrative costs, the diversity of performance metrics places an undue burden on physicians and contributes to high administrative costs. It is estimated that U.S. physician practices spend more than $15.4 billion annually to report quality measures^xvii, and an improved quality measurement system could save up to $7 billion annually^xviii. As detailed in the AAFP's Performance Measurement in Value-based Payment Models for Primary Care, the AAFP believes stakeholders should work together to condense and align measure sets to measure what matters to most in primary care.

• Profiteering & Consolidation – misaligned incentives currently reward consolidation and allow primary care to be leveraged to maximize profits rather than patient care. The motivation behind the integration of primary care practices into larger, consolidated models is the same for both hospitals, corporate entities, and insurers – control of cash flow. Vertical integration can allow primary care to become a leverage point for the pursuit of maximizing savings or profit somewhere upstream. For payers, controlling primary care allows them to oversee and manage care across a patient’s care team and across care settings. For hospitals, it allows them to refer patients to their other employed specialists or seek treatments in their facilities that produce higher profit margins while also ensuring the patient’s care (and costs) stay within a defined health system. In all of these situations, organizations use primary care to meet other financial goals, redirecting revenue away from primary care and failing to invest in the primary care teams that patients benefit from most. Both hospitals and insurers are achieving their financial goals, but the patients and their primary care physicians, in many instances, are not benefiting from these financial windfalls.

• Pharmaceutical & Biologics – advances in pharmaceuticals and biologics have improved the health of millions of people, decreased the prevalence of preventable diseases, and allowed for chronic diseases to stabilize over a prolonged period of time. These advances have extended life expectancy for millions of people, especially those with chronic diseases and some cancers and should be celebrated. However, the escalating costs of pharmaceuticals and biologics places these interventions and treatments out of reach for far too many people. Policies should be established that allow purchasers of health care, including Medicare, to negotiate the costs of prescription drugs. Additionally, there should be greater flexibility in the design of formularies that allow for increased use of generic and bio-similar products. 

• Eliminating Patient Cost Barriers – The current health care system financially rewards individual health care transactions. The AAFP supports providing primary care services to patients without financial barriers, such as co-payments, deductibles and other types of excessive cost-sharing. This is essential when services are provided by the patient’s usual source of primary care and should apply regardless of the payment model through which the patient is attributed. Benefit designs that place high cost-sharing requirements on patients, have onerous in-network and out-of-network rules, and rely heavily on utilization management make primary care less accessible for patients. 

Payment

The AAFP believes primary care payment should support collaborative partnerships between patients and physicians, improve the quality and patient outcomes of care and reduce unnecessary health care spending. The AAFP’s Guiding Principles for Value-based Payment describes the ideal design for key components of primary care payment to increase investment in a less burdensome manner. Additional detail regarding each principle may be found in their corresponding Call-to-Action papers (Establishing Accountability in Value-based Payment Models for Primary Care, Risk Adjustment in Value-based Payment Models for Primary Care, Financial Benchmarking in Value-based Payment Models for Primary Care, Performance Measurement in Value-based Payment Models for Primary Care, Information Sharing in Value-based Payment Models for Primary Care).

The principles build on previous programs and years of research showing the benefits of movement away from a payment system that predominantly relies on fee-for-service (FFS) payment, a payment system that predominantly relies on increased support for population-based care. Such payment better supports small and independent practices, providing an avenue for the sustainability of physician ownership,  and reduces administrative burden in the health care system.

Summary

This framework offers important policy options for the AAFP to move the United States toward a primary care-based health care system in which all people have appropriate and affordable access to health care , are provided a medical home, and have primary care benefits. This can be achieved only if Congress and/or state legislatures act to ensure that these policy objectives are implemented. All people in the United States must have appropriate and affordable access to health care, but this is not sufficient by itself. A fundamental change in the health care system to move toward a primary care-based system is essential to achieve improvements in access, quality, and cost. Extensive worldwide research supports the value of a primary care-based health care system in which all people have access.^XIX This framework is grounded upon the documented value of primary care in achieving better health outcomes, higher patient satisfaction, and more efficient use of resources. The United States will only achieve the type of health care system that our people need, and our nation deserves through a framework of accessible health care for all that is built on a strong foundation of robust primary care.    

References

ⁱ Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001.

ⁱⁱ Institute of Medicine Committee on Quality of Health Care in America. To err is human: building a safer health system. Washington, DC: National Academies Press; 2000. 

ⁱⁱⁱ U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes. Commonwealth Fund.

^iv Lukens, Gideon. Affordable Care Act Improvements Push Uninsured Rate to Another All-Time Low, Though Share of Uninsured Children Rose. Center on Budget and Policy Priorities.

^v Collins S, Schoen C, Davis K, Gauthier A, Schoenbaum S. A roadmap to health insurance for all: principles for reform. October 1, 2007. Accessed July 1, 2018.

^vi Bailit M, Hughes C. The patient-centered medical home: a purchaser’s guide. Washington, DC: Patient-Centered Primary Care Collaborative; 2008. Accessed July 1, 2018.

^vii Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System. Commonwealth Fund. 2024.

^viii The Health of US Primary Care: 2025 Scorecard Report — The Cost of Neglect. Milbank Memorial Fund. 2025.

^ix Dartmouth Atlas of Health Care Working Group. The care of patients with severe chronic illness: an online report on the Medicare program by the Dartmouth Atlas Project. 2006. Accessed July 1, 2018.

^x Basu et al, 2019 https://pubmed.ncbi.nlm.nih.gov/30776056/

^xi National Academies of Sciences, Engineering, and Medicine 2019. Taking Action against Clinician Burnout: A Systems Approach to Professional Well‐Being. Washington, DC: The National Academies Press

^xii Friedberg MW, Chen PG, White C, Jung O, Raaen L, Hirshman S, Hoch E, Stevens C, Ginsburg PB, Casalino LP, Tutty M, Vargo C, Lipinski L. Effects of Health Care Payment Models on Physician Practice in the United States. Rand Health Q. 2015 Jul 15;5(1):8. PMID: 28083361; PMCID: PMC5158241.

^xiii Koller C. Getting More Primary Care-Oriented: Measuring Primary Care Spending. Accessed July 5, 2018.

^xiv Collins S, Piper K, Owens G. The opportunity for health plans to improve quality and reduce costs by embracing primary care medical homes. Accessed July 3, 2018.

^xv 2025 American Medical Association. All rights reserved.

^xvi Dartmouth Atlas of Health Care Working Group. The care of patients with severe chronic illness: an online report on the Medicare program by the Dartmouth Atlas Project. 2006. Accessed July 1, 2018.

^xvii US Physician Practices Spend More Than $15.4 Billion Annually To Report Quality Measures. 2016

^xviii The Role Of Administrative Waste In Excess US Health Spending. 2022

^xix Patient-Centered Primary Care Collaborative. Results and evidence. Accessed July 1, 2018.

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