How Primary Care Investments Can Advance Equity

When adequately supported and designed, high-quality primary care is a common good that provides better population health and more equitable outcomes, according to the National Academies of Sciences, Engineering, and Medicine (NASEM).

But primary care in the United States has been under-resourced for decades, especially in Black, Indigenous, and other historically marginalized communities, resulting in a depleted workforce struggling to deliver care in a weakened infrastructure. The first National Primary Care Scorecard released in February underscores this reality and demonstrates that our current primary care policies are not adequately supporting the delivery of high-quality primary care.

Recognizing this, the federal government recently launched the Health and Human Services Initiative to Strengthen Primary Health Care, and 17 states are adopting legislation to increase investment in primary care. A new report, sponsored by the California Health Care Foundation (CHCF), summarizes decades of research that demonstrate the link between primary care and improved health equity. In this report we argue that more needs to be done – and done differently – to rebuild the foundation of our health care system in an equitable way.

A Paradigm Shift

Our CHCF-sponsored report calls for new ways of thinking and acting as we work to strengthen primary care and ensure these efforts prioritize equity:

• Recognize high-quality primary care as a common good
• Embrace the diversity of primary care practice settings and invest resources according to need with the intentional goal of reducing health and social inequities
• Proactively apply principles of equity and justice to all decisions
• Build accountability for action
• Achieving such a paradigm shift is challenging from a policy perspective. What will policymakers and other decision-makers need to consider as they implement these policies?

Policy Principles

Primary care access, quality, and resources vary widely between communities. These disparities reflect decades of differential investment and fall most heavily on disadvantaged communities, including those at highest risk for health inequities, such as Black, American Indian and Alaska Native populations. More investment in primary care is needed. Any future programs and investments must advance equity in primary care. Specific solutions will (and should) vary across states, but here are four overarching policy principles:

• Commit to immediate action and maintain a long-term perspective on returns. Primary care practices need assistance and more equitable payment models now. Our recent CHCF-sponsored report provides examples of primary care policy recommendations that could be acted on immediately to advance health equity in California and in other states. But successfully addressing long-term deficits in support for primary care and long-standing health inequities requires time, flexibility, and persistence. While evidence supports cost-savings over time, expectations of short-term return-on-investment can perpetuate health care inequities and can undermine long-term commitments to increasing primary care spending and provider payments.
• Create stable, collaborative, sustainable processes for dialogue with primary care practices and communities about their needs.Investing resources according to the needs of diverse primary care practices in the context of their communities starts with prioritizing communities with the least access and availability of high-quality primary care. This must include asking community members, patients, and the practices in these places what they care about and what their priorities are. As a result, governments, payers, purchasers, and others need to find ways to work together to support equity-driven community and practice-level needs assessments (not just one time, but repeatedly) and use the identified priorities to help guide investments in primary care and in efforts to reduce inequities in access, quality of care, and outcomes.
• Think creatively about investments and funding and use multiple approaches to address different needs. Primary care practices in historically marginalized and under-resourced communities need more investments and support to move toward and succeed within flexible, equitable payment models that are value-based. Using small-area deprivation measures — measures based on health in neighborhoods such as the Area Deprivation Index (ADI) or Social Deprivation Index — in addition to patient-specific characteristics, social needs, and health conditions already included in risk adjustment, policymakers and payers can increase payments and investments for practices that serve patients and communities that face higher levels of health and social inequities. Practices also need investments and support to connect effectively with community-based organizations that can help address patients’ health-related social needs such as housing instability, food insecurity, and transportation. In addition, investments in health workforce development are critical so that practices can hire primary care team members from the local community and provide meaningful career advancement opportunities.
• Make all partners accountable for progress, not just primary care practices. Prioritizing equity in primary care is an “all hands-on deck” activity that will require stronger governance and accountability mechanisms that encourage participation and oversight from patients (including people with lived experience dealing with health and social inequities), communities and community-based organizations, practices, public health systems, payers, policymakers, and others. This means that all parties – not just primary care practices – are aligned and accountable for advancing primary care’s essential role in advancing health equity. Massachusetts Health Quality Partners led the way earlier this year by publishing a dashboard of primary care metrics to drive policy initiatives and target resources in the state; other states should follow suit.

Applying These Principles

To forge a path toward health equity, innovative primary care policies and investments are needed in communities across the United States, and a one-size-fits-all approach will not suffice. Strengthening primary care in a way that assures equity for patients, communities, and healthcare workers will require a radical reorientation of payment and policy.

We encourage decision-makers to use new policy levers, or use old levers in new ways, asking these questions:

• Could tax policy be used to provide relief for struggling independent practices, or provide incentives for practices and health systems to partner with community-based organizations to address health inequities?
• What types of new partnerships are possible across levels of government, including municipalities, counties, states, and the federal government?
• Can we leverage public funds and regulations (e.g., through state Medicaid agencies) to align primary care capacity, systems and improvement efforts with broader place-based public health and community-led efforts to advance population health and health equity?

In addition, infrastructure investments can take many different forms. Two possibilities to consider are:

• Funding a federal primary care extension service – primary care extension agents can facilitate community engagement with primary care and public health and collaborate with primary care practices (of all types) in needs assessment, service improvement, and accountability
• Funding Community-Based Organization Networks, hubs that can support contracting between community organizations and healthcare providers

As a common good, primary care should be promoted, protected, and monitored by responsible public policy and supported by private-sector action. Progress is possible. And the time is now.