Primary Care Is Dead. Long Live Primary Care

Kassler is correct, of course (p. 606). The nation would be well served if we provided robust primary care to all Americans. The association between primary care supply, public health outcomes, and lower costs is well known.^1–3 Primary care practices and clinicians are also well positioned to bear witness to the impact of social determinants on population health and to help fire the mobilization needed to change that.

But primary care has been deep trouble for years, trouble that only deepened during the pandemic. Only about 45% of US adults had a meaningful primary care relationship before the pandemic.⁴ The market share and population health impact of primary care is falling.^5,6 The pandemic caused most primary care practices to move the bulk of their “encounters” to telephonic care, a change that fractured primary care relationships, replacing the intimacy of the primary care bond with a phone or video call between a person and a “provider” who could be miles away and not necessarily a part of the person’s community. Many primary care clinicians, already weary of “strangers at the bedside”—Centers for Medicare and Medicaid Services, insurance companies, their employers, and their electronic medical record systems—quit when the pandemic hit. Many more are burned out and disheartened.⁷

And few primary care practices have realized their potential in protecting the public’s health. Too tired or timid to resist third-party demands, too individualistic to organize, and too restrained by the golden handcuffs of a business model that stopped serving the public years ago, primary care clinicians failed to make care accessible to people when and how they needed it and failed to think about the health of the populations they purport to serve, providing

• too few options for same-day care;

• too little use of telephonic care when that was actually appropriate;

• too little integration of mental and behavioral health, use of community health workers, physical therapy and other functionally focused modalities; and

• far too little building of enough capacity to serve entire communities.

They were also beset by a fee-for-service payment system that incentivized all the wrong behavior.

Primary care clinicians and community health centers alike circled the wagons, focused on what they were well paid to do, and did only that, instead of organizing to make sure that the public’s health was protected and the public purpose of primary care was emphasized, encouraged, incentivized, and maximized.

The marketplace happily stepped into this breech. Immunizations are given at retail pharmacies, without any thought of the need for continuity of relationship and prevention planning over time—but perhaps someone is now building an “app” for that. Episodic care is provided in big-box stores and in retail pharmacies. New market players are consolidating primary care practices vertically and horizontally, often carving out profitable market niches—people with Medicare who need chronic care management, people with complex behavioral or substance use disorder needs, and so forth. We now have market segments, not a coherent public for those few primary care practices that think about the public’s health to engage.

The pallid attempts to transform primary care over the past 10 years or to integrate primary care into public health were too weak-wristed and have come too late to be meaningful.

It is just too late for dialogue. The United States has chosen marketplace medicine over a primary care–based not-for-profit health care system that serves all Americans. Primary care is likely dead as a public health tool, unless primary care clinicians and the public organize and build a health care system that serves all Americans. We have already lost more than 476 000 lives and will likely lose 250 000 more before this pandemic comes under control. Without a meaningful primary care delivery system that serves all Americans, we remain woefully unprepared for the next one.