Primary Care as a Public Utility: The Case for a Common Fund

More than one-third of US adults lack access to primary care, which has increasingly become a commodity rather than the common good envisioned by the National Academies of Sciences, Engineering, and Medicine. Many states are working to bolster primary care, but face common challenges related to federalism, fragmentation of health insurance, and administrative hurdles that undermine their efforts to invest in primary care. These challenges are discussed and one potential solution is described: a primary care common fund that finances and pays for primary care from the perspective of a public utility.

State investments in primary care are often limited to populations whose health insurance is subject to state authority, including state employees, Medicaid enrollees, and fully insured commercial lives. This leaves self-insured commercial lives, Medicare beneficiaries, and other populations (often totaling more than half of a state's population) untouched. Moreover, state mandates to spend more on primary care through a pluralistic insurance system are subject to payer mix and market power differences in the delivery system, which can lead to inequities in financial support across practices and patient populations. One solution to these challenges is a primary care common fund, which pools primary care spending from public and private purchasers and pays practices directly. This provides conceptual and practical advantages related to patient freedom, state choice, administrative burden reduction, and payment flexibility, which can include alternative payment models reflecting state preferences around non-fee-for-service incentives. Furthermore, this can be done without altering the insurance, payment, and delivery of health care outside of primary care. Precedent exists for such an approach to financing and paying for common goods by states.

As people in the US increasingly struggle to find a primary care clinician, state investments in primary care share common challenges. A primary care common fund could help states overcome these challenges by pooling resources and paying for primary care as a public utility-consistent with the vision of primary care as a common good-without disrupting the rest of the health care system. This approach is supported by precedent and paths toward feasibility.