Primary Care Deep in the Heart of Texas

The Waco Chamber of Commerce, in its most recent publication, breathlessly welcomes readers to “an amazing community of innovators, builders, and doers.”

Straddling the banks of the Brazos River and about halfway between Austin and Dallas, Waco has a population of about 140,000, with another 110,000 people in McLennan County. Notwithstanding the chamber’s boosterism, the city is what one resident called “a pretty typical mid-sized Texas town” with its own economic and social strengths and challenges.

The town’s growing Hispanic population comprises 40% to 45% of the city’s total. Waco and its surroundings are not wealthy. According to County Health Rankings, McLennan county, compared to the rest of Texas, has more kids in poverty, fewer of them reading at third grade reading levels, more housing instability and higher income inequality. One in five households live at or below the federal poverty level.

Those of a certain age may associate Waco with the bloody Branch Davidian standoff in 1993. Fortunately, that tragedy has been eclipsed by the town’s status as the host of home renovation show, “Fixer Upper.”

Originally a cattle and agricultural center, Waco saw light industry such as clothing and machinery come in over last century. The town’s primary economic driver is Baylor University. The largest employer in town and the home of a top 10 men’s basketball team, Baylor promotes its “R1” status as a research university, pursuing an agenda of “health, data sciences, human flourishing and leadership and ethics.” Other large employers in the area are what one might expect — the school district and lots of retail.

Besides education, the other big employer in town is health care. Two health systems — Ascension Health and Baylor Scott and White — compete for patient and clinician loyalty, underscoring the tension between health care’s status as an economic driver and as a resource to improve the health of the population.

And the health needs are many. According to the same county rankings, McLennan has a higher incidence of obesity, adult smoking, and sexually transmitted diseases than the Texas averages. Self-reported fair or poor health status is worse, as is the incidence of low birthweight babies.

A key health resource for addressing these needs is a robust primary care infrastructure. We at the Milbank Memorial Fund, with additional support from The Physicians Foundation, released our Health of US Primary Care Scorecard last month. It was the first attempt to assess the strength of primary care infrastructure at the national and state levels.

The report draws its inspiration, and most measures, from the 2021 National Academy of Science Engineering and Medicine report on implementing high-quality primary care. Overall, the news is not good:

1. The US is underinvesting in primary care.
2. The primary care physician workforce is shrinking and gaps in access appear to be growing.
3. The percentage of adults who do not report a usual source of care is growing.
4. Too few physicians are training in community-based settings, where care is needed the most.
5. There are few federal funding opportunities for primary care research,

So how does this play in the heart of Texas? Primary care in Waco, it turns out, has its work cut out for it, but also bright spots, thanks to longstanding and new community commitments.

Finances for primary care in Texas, according to the scorecard’s data dashboard, do not look great. All-payer investment in primary care rose between 2016 and 2020 but was still pretty paltry. Of particular concern was the decline in the rate for Medicaid, compounded by the fact that the state has not expanded the program to reach the one in five McLennan residents who remain uninsured.

The NASEM report emphasized that investment is not only about how much money is flowing to primary care but how it is delivered. Echoing the scorecard findings, primary clinicians in Waco report to me little adoption of per person monthly payments to their practices, which would have been a particular boon during the worst of the pandemic, when visit rates plummeted and practices struggled to keep their doors open.

The news around access to primary care in Waco is brighter. The ratios of county residents to primary care and to behavioral health providers are both about 20% lower (or better) than state averages. That access is highly segregated by payer, however. The high uninsured rates and low Medicaid payments found in Texas limit the ability of many residents to see many of those providers. Waco Family Medicine, Waco’s only federally qualified health center, serves 62,000 unique patients a year, over 70% of whom have incomes below poverty level.

The relatively good news about primary care access in Waco is due to longstanding community workforce strategies. Since 1969, Waco has hosted a large and well-respected community-based family residency program. A cooperative agreement, originally between the city’s two largest hospitals and the predecessor to Waco Family Medicine, has survived multiple organizational changes, allowing physician residents to continue to get the bulk of their training at one of the 15 sites out of which Family Health Center operates. The nationally renowned program now produces 12 graduates a year, most of whom remain in the region.

As a result, over 80% of the family medicine physicians in the region are graduates of the residency program. As Jackson Griggs, MD, Waco Family Medicine’s CEO, notes, each one has been trained in a predominantly community-based, rather than hospital-based, setting. This training exposes residents to the importance of assessing and meeting patients’ social as well as clinical needs. It also steeps them in team-based care, particularly when meeting the considerable behavioral health needs of the population.

The maturity of the residency program provides a strong base for primary care–focused clinical research. However, local research could benefit from more funding opportunities to deepen the community’s capacities to understand and meet its population health need. As the primary care scorecard documented, less than one-third of a penny of every National Institutes of Health (NIH) dollar is going to primary care research. More NIH dollars for primary care would spur additional collaboration and synergies between the Waco Family Medicine’s residency program and researchers at Baylor, which so far, Griggs notes with regret, has been promising but limited in size and scope.

Building on the strengths of the region’s primary care infrastructure will also take changes in federal and state policy. The Texas Primary Care Consortium, a project of the Texas Health Institute with support from Episcopal Health Foundation and Saint David’s Foundation, is a broad multistakeholder group working to build support for primary care in the Longhorn state. Their state policy agenda constitutes a thoughtful, evidence-based public policy approach (Figure 1).

Figure 1

The Waco Chamber of Commerce is right: When it comes to improving the region’s health and health equity, the are some amazing innovators, builders, and doers. Those folks also have had the wisdom to maintain what has been built, like Waco Family Medicine’s residency program. They continue to face significant barriers, however, such as insufficient financing, poorly coordinated payment models, and needlessly poor and uninsured populations. There are significant opportunities to strategically leverage community assets — as Baylor, the community’s largest employer, aspires to do — to take on the issues. But it will take leadership and public-private sector partnerships, as well as data such as that found in the scorecard, to inform changes in federal and state health policy.