Analysts push primary care beyond traditional insurance
A universal primary care common fund could redraw how Americans finance first-contact care, and the idea is drawing serious attention from policy analysts, physician leaders, and health system reformers. At an open meeting of the National Academies of Sciences, Engineering and Medicine Standing Committee on Primary Care on Nov. 12, panelists weighed whether primary care should remain tethered to legacy insurance structures or move toward a separate financing model designed to deliver continuous access regardless of a patient’s health plan.
The proposal is straightforward in concept and complicated in execution. A common fund would provide continuous financial coverage for primary care across insurance status, with the aim of reducing fragmentation and making it easier for patients to maintain a stable source of care over time. R. Shawn Martin, executive vice president and chief executive officer of the American Academy of Family Physicians, endorsed the idea as the right direction while acknowledging that it is not yet ready for broad adoption because payment design, regulation, and governance remain unsettled.
“I think big reforms come from big ideas that make people uncomfortable,” Martin said during the discussion. “If we’re really serious about primary care as a foundation for the health care system … we’ve got to get really comfortable with being uncomfortable about insurance.”
The tension is easy to see at the bedside. Primary care depends on continuity, yet the current payment structure often rewards episodic volume, administrative compliance, and downstream specialty billing rather than the longitudinal work that keeps patients stable. A financing model that pays for the function of primary care, rather than only the claims attached to individual visits, could shift incentives toward prevention, coordination, and relationship-based care.
Payment design, insurance coverage, and access pressures
The discussion quickly moved from philosophy to mechanics. Zach Gaumer, vice president of health policy at the Bipartisan Policy Center, asked how a common fund would actually pay clinicians: through the existing physician fee schedule, through bundled payments similar to those used by federally qualified health centers, or through another structure entirely. He also asked who would finance the fund, a question that sits at the center of whether the proposal can move beyond concept papers and pilot projects.
Matthew Rae, associate director of the Program on the Health Care Marketplace at KFF, described the common fund as a compelling answer to fragmentation because it could give patients consistency across their lives. He also flagged the inevitable interaction with private insurance, which is where many policy proposals become difficult. Primary care may not need to remain embedded inside conventional insurance arrangements, but insurance still matters for catastrophic and specialty costs, as well as for protection against broader health care utilization.
Rae added a sobering warning about the coverage outlook. KFF estimates that about 14 million people will lose health insurance by 2034 because of Medicaid changes and the expiration of enhanced premium tax credits. The National Academies report cites lower Congressional Budget Office estimates of 9.1 million to 10 million. Even at the lower end, the implications for primary care are severe. People who lose coverage are about four times less likely to have a usual source of care, and a shrinking insured population translates into weaker access, more delayed diagnosis, and more avoidable emergency utilization.
Coverage losses are not abstract budget effects. They change whether a patient shows up early with hypertension, diabetes, asthma, depression, or an evolving cancer symptom—or waits until illness forces a crisis visit.
For patients who remain insured, Rae said first-dollar coverage of primary care would improve access by reducing cost-sharing friction. In practical terms, eliminating copays and other upfront barriers can make the difference between a timely visit and a skipped appointment, especially for low-income families, people with chronic disease, and patients juggling transportation, childcare, and hourly work schedules.
Redirecting dollars toward the function of care
Martin argued that too much health care money is intercepted by intermediaries before it reaches the people delivering primary care. His complaint was not limited to salaries. He said the system should move money toward the function of primary care itself, with payment mechanisms that support time, continuity, coordination, and physician judgment.
“I think the money has to flow to primary care,” he said, adding that there are “an enormous amount of financial intermediaries” absorbing funds in the system. He also said cost sharing acts as both an economic and behavioral disincentive to primary care and should be removed.
The administrative load received equal criticism. Martin said quality checklists and utilization management requirements often intrude on the physician-patient relationship and should be scaled back so clinicians can navigate care through shared goals rather than paperwork. In modern primary care, the hidden work matters: medication reconciliation, referral coordination, preventive counseling, social needs screening, and the repeated follow-up that prevents minor problems from becoming irreversible.
A stronger primary care financing model would also need to address workforce decline. The National Academies report recommends at least doubling funding for the National Health Service Corps and shortening the timeline for Public Service Loan Forgiveness, but Martin said those steps alone are not enough. He called for major tax reform, including above-the-line tax credits for people who enter primary care and for those who practice in rural communities.
His preferred example was concrete: a $75,000 above-the-line tax credit for five to 10 years for people who choose community-based primary care. He described the idea as “ground-shaking,” and in a workforce market defined by medical school debt, rural shortages, and mounting burnout, that is not an overstatement.
Pilot testing the model and the policy hurdles ahead
Gaumer suggested that a state pilot could help answer the most basic implementation questions: what care actually costs, how the common fund would operate, and which payment model would best support access without introducing new inefficiencies. Those are not small questions. A universal primary care fund would require decisions about who contributes, how risk is shared, how clinicians are paid, and how the model interacts with Medicare, Medicaid, employer-sponsored insurance, and individual market plans.
The proposal also raises a broader issue about autonomy. Primary care can only function as a stable point of entry if clinicians have enough independence to respond to patient needs without being overwhelmed by payer checklists or constrained by narrow billing categories. Financing reform alone will not solve access problems, but without financing reform, the rest of the system keeps leaning on a broken foundation.
One policy lever Martin said could change behavior quickly was a large, direct tax credit for entering community-based primary care. By sending money directly to clinicians rather than routing it through loan repayment or indirect incentives, the policy would treat primary care as a national priority rather than a residual service line.
The unresolved challenge is not whether primary care needs more money. It does. The harder question is whether policymakers are willing to separate primary care from the insurance machinery that has long governed it, then build a payment structure that rewards continuity, access, and clinical judgment instead of transaction volume. The National Academies discussion made clear that the idea is now part of serious policy debate, but the mechanics remain unfinished.