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Andrew Harrer

In a bid to rectify key failings in the country’s fractured health-care system, the Biden administration this fall released plans to shore up primary care. The initiative has won praise from some experts for its ambitions, though others warn it does not go far enough to resolve a growing crisis in care linked to health inequities, high maternal mortality rates and even the country’s dramatic <a href="https://www.washingtonpost.com/health/interactive/2023/american-life-expectancy-dropping/" target=_blank>decline in life expectancy</a>.

The report, published in November by the Department of Health and Human Services, outlines some steps to change the financial incentives that have hampered access to primary care. It draws extensively on recommendations published in 2021 by the National Academies of Sciences, Engineering, and Medicine that called for a shift away from the fee-for-service system, which rewards physicians for treating sick people rather than for preventing them from becoming ill in the first place.

“It’s the single best explanation of what’s wrong and what Uncle Sam can realistically do to tackle the problem,” said David B. Nash, a physician and professor of health policy at the Jefferson College of Population Health at Thomas Jefferson University in Philadelphia who had been skeptical about the report before its release.

While some experts praised the initiative, others who have followed the process closely describe it as a missed opportunity. They note that the report is an “<a href="https://www.hhs.gov/sites/default/files/primary-care-issue-brief.pdf" target="_blank">issues brief</a>” released in place of a long-promised departmentwide action plan that would have been coordinated by a centralized leadership team.

“The issues brief is a summary of what’s being done, not a forward-looking document,” said Christopher F. Koller, president of the Milbank Memorial Fund, a foundation devoted to improving population health.

HHS declined to say why the more comprehensive action plan was shelved but emphasized the department’s continued commitment to strengthening primary care. People familiar with the process, who spoke on the condition of anonymity to describe internal discussions, described months of delays and setbacks, including a breakdown in the leadership structure, leaving it up to individual agencies to decide whether to follow through. Judith Steinberg, a key figure in the leadership team, has announced her retirement from federal service and did not respond directly to a request for comment.

The HHS initiative has grand goals and limited financial resources, because the funding is carved out of the agency’s existing budget. It aims to advance the Biden administration’s focus on reducing health inequities and ensuring that federal government programs reach underserved communities. It also outlines plans to improve overall health outcomes by addressing the overdose epidemic and the child and adolescent mental health crisis. And it charts a path for improving maternal health care and promoting partnerships between primary care and public health.

“Primary care is one of the few interventions that has been shown to improve health outcomes,” said Shantanu Nundy, a primary care physician who works for a virtual care company and at a federally qualified health center. The current system devalues routine preventive care in favor of expensive treatments, he said, and “Americans are living poorer-quality and shorter lives as a result.”

Some experts said despite its challenges, the initiative represents an important step toward relieving problems in the country’s health system.

One goal involves the Centers for Medicare and Medicaid Services, which drives much of the health-care marketplace, increasing the portion of spending that goes to primary care. The report outlines plans to provide additional payments for primary care providers and create a payment and care delivery model in eight states called Making Care Primary, which aims to allow patients greater ease in accessing high-quality care.

Assistant Secretary for Health Rachel Levine, whose career has been in primary care as a pediatrician, did not provide direct comment but praised the effort on the social media platform X, formerly Twitter.

“<a href="https://twitter.com/hashtag/PrimaryCare?src=hashtag_click" target=_blank>#PrimaryCare</a> is essential for improving the health and well-being of individuals, families, and communities,” Levine wrote. “<a href="https://twitter.com/HHSGov" target=_blank>@HHSGov</a>, we are investing in numerous efforts to improve equitable access to whole-person primary care.”

For decades, health systems experts have called for better access to comprehensive, community-based services, in part because the lack of easily accessible entry-level care has been linked to the United States’ decline in life expectancy, making the richest country in the world an outlier among developed nations.

U.S. life expectancy, which used to be closely tied to a nation’s wealth, peaked in 2014 at 78.9 years and had fallen to as low as 76.4 in 2021, according to the Centers for Disease Control and Prevention, returning to the levels of the mid-1990s. A <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2724393" target=_blank>2019 study</a> published in JAMA Internal Medicine found that every 10 additional primary care physicians per 100,000 people was associated with a 51.5-day increase in life expectancy.

Meanwhile, the field of primary care is attracting fewer medical students, in part because family doctors are paid far less than specialists.

“Medical students see who the heroes and heroines are,” Nash said. “They see it’s the specialists who get all the kudos.”

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Robert L. Phillips, co-director of the Center for Professionalism and Value in Health Care, who was a leader of the National Academies study, said he was glad to see the study group’s objectives reflected in the federal initiative, even though he is uncertain which parts of the original plan HHS will continue to pursue.

“It was a huge amount of effort on their part,” said Phillips, a professor of family medicine at Georgetown University. His key concern now is accountability and identifying the “choir director” to coordinate the effort and the key figure responsible for making it all work. Phillips is looking forward to examining the new data-driven Primary Care Dashboard, a tool designed and managed by HHS to monitor the “health” of the initiative and inform subsequent actions. HHS said a first report from the dashboard should be ready in 2025.

Nundy, who is the chief health officer of Accolade, a company that provides virtual primary care and mental health services in all 50 states, and also a primary care physician at Neighborhood Health in Northern Virginia, said he felt there was “a lot missing from the report.” The approach, he said, seemed backward-looking at a time when technology — including telehealth — offers the possibility of transforming the delivery of care.

“I had the sense the report was trying to put the genie back in the bottle, going back to Marcus Welby,” Nundy said, referring to the popular 1970s TV series that featured a beloved family doctor. While that model might still work for some segments of the population, he said, others might be better served by community health workers or other systems.

“College students, do they need a full MD or a counselor?” Nundy asked as an example.

Koller, of the Milbank Memorial Fund, praised the objectives of the HHS initiative while warning that the federal government alone cannot provide the overhaul necessary to make primary care accessible to all.

“This doesn’t all just depend on public action. I’ve been there,” said Koller, a former health insurance commissioner in Rhode Island who collaborated with Phillips on the National Academies report. “You need organized partners outside of government.”

Change also will require help from Capitol Hill, Phillips and other experts said. In an <a href="https://www.washingtonpost.com/washington-post-live/2023/10/17/transcript-health-innovation/" target=_blank>interview with Washington Post Live</a> shortly before the issues brief was released, HHS Secretary Xavier Becerra said the process of strengthening primary care was already underway. “We’re doing some,” Becerra said, “but we need our friends down the street in Congress to give us the resources to fully make it happen.”

In September, Sens. Bernie Sanders (I-Vt.) and Roger Marshall (R-Kan.) announced a <a href="https://www.sanders.senate.gov/wp-content/uploads/Bipartisan-Primary-Care-and-Health-Workforce-Act-Summary_09.14.2023.pdf" target=_blank>$26 billion legislative bill</a> aimed at expanding primary care and reducing staffing shortages. The impact of that bill is likely to be limited, partly because it is focused almost exclusively on federally qualified health centers, which cater to less than 10 percent of the population, while the problems with primary care are far more extensive.

The HHS initiative also does not change an essential flaw in the current financial structure, which relies on a physician visit to initiate the billing process. If a community health worker first knocks on somebody’s door, there is no way to reimburse that visit. Those problems became clearer during and after the pandemic, which put a spotlight on how few people have a lasting relationship with a primary care doctor. The challenge is to figure out ways to pay for entry-level services and care providers beyond the family doctor.

“Given the shortages and trust issues, it makes much more sense for people to be allowed to see those other health professionals first,” Nundy said. “The whole system bottlenecks on the physician.”

Meanwhile, family doctors are increasingly hard to come by, even for people with good insurance. Brian Gamborg, who worked as a family doctor in Saskatchewan and in Louisiana, where he was president of the Parish Medical Society and Board of Governors of the State Medical Society, said that during his four-decade career, he has witnessed the chilling impact of private equity, venture capital and large corporations such as CVS and Walmart buying up primary care companies.

If the HHS initiative helps attract any young doctors to careers in primary care, he will be pleased, he said.

“I retired at the end of June,” Gamborg said, “and cannot for the life of me find a real family physician other than my former partners, who are overwhelmed.”

Visiting Fellow, Lady Margaret Hall, Oxford University, 2017 - 

Visiting Fellow, Reuters Institute for the Study of Journalism, 2017

Press Fellow, UN Foundation, 2015

Press Fellow, Wolfson College, Cambridge University, 2006

Alicia Patterson Foundation Fellow, 2003

British Thouron Scholar 

Journalist in Residence, Max Planck Institute for Comparative Public Law and International Law, 2024

University of Pennsylvania, MA in linguistics

University of Oxford, BA (Hons) in modern languages

Frances Stead Sellers is an associate editor of The Washington Post. 

Frances Stead Sellers

HHS falls short in plan to revitalize nation’s primary care, experts say

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