Medicare Pay Still Trails the Work Primary Care Performs
Primary care in the United States remains underpaid, and the gap is not closing fast enough to protect access. A five-year update from the National Academies of Sciences, Engineering and Medicine says the country has made little progress since the 2021 call for stronger primary care, while recent federal policy is likely to move access in the wrong direction.
The update, Ensuring Access to High-Quality Primary Care in the United States, extends the earlier national assessment, Implementing High-Quality Primary Care, and comes with a blunt message for physicians, health systems, and payers: the financing model still does not match the role primary care plays in longitudinal care, prevention, and coordination. Andrea A. Anderson, M.D., M.Ed., and Alex H. Krist, M.D., M.P.H., co-chaired the committee behind the report.
The imbalance is visible in federal payment data. Between 2017 and 2023, total annual Medicare Physician Fee Schedule payments to primary care physicians per beneficiary fell from $438 to $420. Over the same period, payments for primary care office visits declined from 9.1% to 8.4% of total fee schedule spending. Higher evaluation and management values and the G2211 add-on code for longitudinal care did not produce the rebalancing that many clinicians had hoped for, in part because specialists account for the plurality of billing for those codes.
Primary care cannot be asked to carry more responsibility while receiving a shrinking share of the financing.
Access Gaps Are Already Large and Still Widening
The report anchors its access concerns in the annual primary care scorecard produced by the Milbank Memorial Fund, the Physicians Foundation, and the Robert Graham Center. In 2023, 29.7% of U.S. adults reported having no usual source of care, up from 28.7% in 2021 and 23.6% in 2010. Among children, 13.9% lacked a usual source of care in 2023.
Those figures matter because a usual source of care is not a bureaucratic detail. It is the clinical entry point for blood pressure checks, diabetes monitoring, medication reconciliation, cancer screening, immunization, behavioral health triage, and the kind of early intervention that prevents avoidable emergency use. When nearly 3 in 10 adults and 1 in 7 children lack that anchor, the system shifts care downstream, where treatment is more fragmented and more expensive.
The committee estimates that high-performing, team-based primary care costs about $75 per member per month for a general population and $111 per member per month for patients with high social needs. Devoting 10% of total U.S. medical spending to primary care would yield roughly $113 per member per month, enough to cover both levels. That calculation forms the basis for the committee’s benchmark: at least 10% of total health care spending should go to primary care, about twice the share it receives now.
Coverage Losses Would Hit Primary Care First
Federal policy since 2021 is described as likely to further compromise access, largely by reducing health insurance coverage. The report points to several Congressional Budget Office estimates tied to H.R. 1, now Public Law 119-21. The estimates differ because they use different baselines, time frames, and combinations of policies, but each points in the same direction: fewer insured patients and more strain on primary care practices.
One CBO estimate projects 10 million more uninsured people by 2034 compared with the preenactment baseline. An earlier estimate cited in the report put the figure at 9.1 million people losing insurance by 2034, including 7.8 million because of Medicaid changes and 1.3 million because of private insurance changes. A separate projection cited in the report places the uninsured population at 26.6 million in 2025 and 37.4 million in 2036 when the law is combined with the expiration of enhanced Affordable Care Act premium tax credits.
Starting Jan. 1, 2027, 44 states must begin conditioning Medicaid eligibility for expansion adults on work or community engagement requirements. The report warns that these requirements add documentation burdens for clinicians, especially when practices must verify patient exemptions. A recent survey found 44% of Medicaid members were unprepared for the requirements, a finding that suggests implementation will be messy and burdensome long before any policy goal is achieved.
When coverage falls, primary care absorbs the shock first. Practices see more uncompensated care, more deferred visits, and more patients arriving with preventable complications that should have been caught earlier.
Workforce Expansion Cannot Be Left to Chance
The report pairs payment reform with a workforce strategy, arguing that access will not improve without a larger primary care workforce. One recommendation calls for tying future Medicare-funded graduate medical education expansion to institutions that already produce primary care clinicians and reserving some new slots for primary care trainees. Another calls for Congress to fund at least twice as many Teaching Health Center residents and to make that funding mandatory, with adjustments for new sites and inflation.
Loan relief also appears in the committee’s framework, though the article’s provided text cuts off before the full recommendation is completed. The intent is clear from the surrounding context: recruitment into primary care will remain difficult if training pathways leave physicians with heavy debt and comparatively weak compensation.
This is not only a workforce issue; it is a delivery-system issue. Primary care depends on continuity, panel management, nurse and care-manager support, and time for longitudinal follow-up. Undervaluing that work pushes clinicians toward shorter visits, thinner teams, and less capacity to absorb high-need patients.
The Policy Prescription Centers on Reinvestment and Shared Funding
The committee’s six recommendations are direct. First, HHS and Congress should help states establish a primary care common fund that provides universal coverage for primary care, pays standardized rates that appropriately value the service, and eliminates patient cost sharing. As an alternative, Congress should consider a federal common fund run by CMS.
Second, payers should require health systems to reinvest any additional primary care payments back into primary care practices. Without that guardrail, new money can disappear into unrelated budget lines while frontline clinics remain understaffed.
Third, state regulators should push primary care spending to at least 10% of total health care spending, including prescription drugs, and require health plans to report how provider organizations use the added money. Transparency matters because more spending alone does not guarantee stronger access if the money is absorbed elsewhere.
The final recommendations focus on training: future Medicare GME expansion should favor primary care-producing institutions, Teaching Health Center funding should be doubled, and loan relief should be expanded. The committee’s view is straightforward: access will not improve unless payment, training, and policy are aligned around the same goal.
What Primary Care Practices Face If Nothing Changes
The report leaves little room for complacency. Payment remains misaligned, coverage is at risk, and the workforce pipeline is still too small for the country’s needs. For individual practices, the consequence is immediate: more uninsured patients, more uncompensated care, and more pressure to do population health work without the resources that work requires.
For patients, the result is slower access to diagnosis and treatment, more fragmented chronic disease management, and a weaker connection to the health system when the first symptom appears. For policymakers, the central question is not whether primary care matters. It is whether federal and state financing will finally treat it as infrastructure rather than an afterthought.
The report’s own benchmark is concrete. If the country is unwilling to direct at least 10% of health care spending to primary care, the access problem will keep growing while practices are asked to absorb more of the fallout from coverage losses and workforce shortages.