On May 4, 2021, the National Academies for Sciences, Engineering and Medicine (NASEM) released a major report expressing a dire need to improve primary care in the U.S.¹  Since January 2020, an extensive committee within NASEM has worked to develop an implementation plan that will reopen the discussion of improving primary care as a means to improving overall health and achieving health equity.²

Serious conversations related to health reform in primary care started over 25 years ago with the 1996 Institute of Medicine (IOM) report entitled, “Primary Care: America’s Health in a New Era.”³ However, the 1996 IOM report’s recommendations were thwarted by the collapse of the Clinton healthcare reform efforts a couple of years prior, and the resulting reticence to take on further reform efforts.⁴ MCOs are a form of health insurance in which a referral from a primary care physician (PCP) is needed for all non-emergent services and members are usually required to stay in the MCO’s network of providers. They were established in the 1970s to help control rising healthcare costs. However, by the time the IOM report was completed, MCOs were failing and the political window of opportunity to improve primary care had closed.⁵ Then, nearly 25 years after the IOM report was published, NASEM began to establish its committee to revisit some of the IOM’s recommendations and create an implementation plan to improve primary care in the U.S. Shortly following the committee’s creation, the COVID-19 pandemic struck the U.S. and made gaps in access to healthcare and poor health outcomes glaringly obvious.⁶ The NASEM committee strove to develop an action plan to improve the delivery of primary care in the U.S. with the following five objectives:

1. “Pay for primary care teams to care for people, not doctors to deliver services;”
2. “Ensure that high-quality primary care is available to every individual and family in every community;”
3. “Train primary care teams where people live and work;”
4. “Design information technology that serves the patient, family, and interprofessional care team;” and
5. “Ensure that high-quality primary care is implemented in the United States.”⁷

The second objective quickly became the most notable, with Action Item 2.1a causing the most controversy in the short time since the report’s released.⁸ This action item calls on the Centers for Medicare & Medicaid Services (CMS) to be the first payor to ask every beneficiary they cover to annually declare a source of primary care, and assign a provider to any non-responding enrollees.⁹ NASEM then recommends that CMS push its state partners, as well as commercial insurers and employers, to do the same.¹⁰ The report does not guarantee federal action, but NASEM reports have spurred health policy initiatives in the past, such as improving quality of care by reducing medical errors.¹¹ Additionally, the recent NASEM report was supported by well-known organizations such as the American College of Physicians, Blue Shield of CA, the Commonwealth Fund, and approximately 15 others.¹² These endorsements add further credibility to NASEM’s recommendations and may help achieve support from CMS and private payors.

Action Item 2.1a has garnered significant attention for several reasons. On one hand, assigning every beneficiary a PCP could be means to improving the health of Americans, as the U.S. has the worst health outcomes of wealthier nations.¹³ NASEM researchers found that better access to primary care is a public health measure that will increase timely diagnoses, enhance management of chronic diseases, and lead to overall coordinated care.¹⁴ Currently, the U.S. spends 5% on primary care versus other wealthy democracies, whose spending averages around 14%.¹⁵ Increasing spending on primary care would emphasize a platform for continuous, person-centered care that would consider the needs and preferences of individuals, families, and communities.¹⁶

On the other hand, there are worrisome implications to such a mandate. First, a central requirement to this action item to make healthier people and healthier communities is to increase the supply of primary care. However, the U.S. is already experiencing critical primary care shortages and projections estimate that by 2033, PCP shortages could reach between 21,400 and 55,200.¹⁷ Physicians would rather enter more lucrative specialties where they are less likely to experience burnout.¹⁸ Such a shortage has significant consequences for those who live in rural areas and may not have access to primary care outside of the emergency department. Indeed, a 2019 Journal of the American Medical Association study confirmed that rural residents already consume over one-fifth of all emergency department visits.¹⁹ Second, should the government adopt NASEM’s recommendations, it would not be the first attempt to link patients to a PCP. Up until the 1990s, popular MCOs such as Kaiser Permanente used PCPs as “gatekeepers” that would refer patients to specialists as a way to keep premiums low. Originally hailed as a means for reducing health costs, these models instead caused physicians and hospitals to underprovide services for fear of surpassing their spending thresholds and by the late 1990s, driven by strong patient discontent, these companies were experiencing hundreds of millions of dollars in annual losses.²⁰ These organizations ultimately struggled to strike the right balance between gatekeeping to keep costs low, and giving patients the autonomy to seek care when needed.²¹

Any initiatives stemming from NASEM’s recommendation to require patients to have PCPs could also receive backlash from patients themselves. First, patients may be concerned with what an annual enrollment period to choose their PCP would look like, and if all dependents on their health plan would have to use one specific PCP. Additionally, patients may be concerned that assigning a PCP may turn into gatekeeping. However, the NASEM committee addressed concerns with solutions that include a new generation of medical systems. They proposed that with new advanced primary care systems, emphasis on primary care should not limit access to overall care.²² Their focus is to improve continuity of care, which will in turn provide better preventative care, higher patient satisfaction, and better management of chronic conditions, while lowering costs.²³

Since the initial IOM report, primary care has drastically changed in the U.S. and has driven care to become fragmented and expensive.²⁴ The goal of NASEM’s report is to make primary care a common good to increase overall health and make chronic conditions easier to manage.²⁵As the U.S. looks to solutions to improve the broken foundation of primary care and promote high quality care, assigning a PCP may be a solution to increase access for patients while simultaneously keeping costs down.²⁶