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The state of access to primary care in the United States has crossed a line from which recovery will be difficult. A decade ago, the number of physicians entering the primary care workforce was not sufficient to replace the existing primary care workforce,14 and this phenomenon has only gotten worse due to retirement, burnout, and a reduction of clinical hours.15 The explosion of delivery models such as telehealth-only primary care, retail clinics, and urgent care has fragmented the primary care workforce into two distinct arms: one that provides traditional primary care that is based on a continuous patient-clinician relationship, and one that provides episodic and fragmented care.16–19 Furthermore, the US population is growing and aging, increasing the demands on an already overextended workforce.9 Health crises such as the opioid epidemic and the increasing behavioral health needs of the nation post-COVID have also left primary care in high demand but short on resources.20
As a result of this mismatch between the supply of primary care and the demand for primary care, patients are suffering, and the nation is less healthy than a decade ago; life expectancy is lower,21,22 the gap in access to primary care between underserved and non-underserved areas is increasing,2 and health issues like obesity, unmanaged behavioral health conditions, and maternal mortality are on the rise.23–26
For individual patients, fewer health care needs are being met,27,28 new patients are struggling to get appointments with primary care offices, and wait times to see a primary care clinician (for those who already have one) are nearly a month long.1
One marker of access is whether people have a familiar provider they can turn to when they are sick or in need of medical advice, also known as a “usual source of care.” A usual source of care improves health and reduces inequitable outcomes. People with a usual source of care have better access to care,29 higher rates of preventive service use,30 better control of their chronic diseases,31 and report higher levels of satisfaction with their care.32
Over the past decade, however, the percentage of adults and children who report not having a usual source of care has been rising (Figure 1). There has been a 36% increase in the share of children and a 21% jump in the share of adults without a usual source of care from 2012 to 2021. Given multiple reports of children falling behind on their preventive care during the pandemic33,34 and the rising burden of mental health issues in children and adolescents since the pandemic,35,36 the drop in children reporting a usual source of care after the pandemic is cause for concern.
My primary care doctor knows about my family, and I know about his family. He’s so important in my life. When he comes in the [examination room], he knows all the doctors I see, and all that I’m going through, and I appreciate that. He’s not walking in the room without knowing what’s going on; sometimes I don’t want to explain it again.Yunina Graham, patient, San Francisco
My primary care doctor knows about my family, and I know about his family. He’s so important in my life. When he comes in the [examination room], he knows all the doctors I see, and all that I’m going through, and I appreciate that. He’s not walking in the room without knowing what’s going on; sometimes I don’t want to explain it again.
Data Source: Analyses of Medical Expenditure Panel Survey data, 2012–2021.Notes: Usual source of care (USC) ascertained whether that is a particular doctor’s office, clinic, health center, or other place where the individual usually goes when sick or in need of health advice. No usual source of care includes those who reported no usual source of care and those who indicated the emergency department as their usual source of care.
Beyond the data, the reality of poor primary care access is gaining public attention. In the lastyear, national news stories about the problem have proliferated. Headlines such as “Primary Care Saves Lives. Here’s Why It’s Failing Americans”4 and “The Shrinking Number of Primary Care Physicians Is Reaching a Tipping Point”5 point to the diminishing availability of primary care physicians and long wait times for primary care visits.
In response to our crumbling primary care infrastructure, a National Academies of Science, Engineering, and Medicine (NASEM) committee published a landmark report in 2021, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.8 The report offered 16 recommended actions to achieve five objectives: (1) Pay for primary care teams to care for people, not doctors to deliver services, (2) Ensure that high-quality primary care is available to every individual and family in every community,(3) Train primary care teams where people live and work, (4) Design information technology that serves patients, their families, and the interprofessional primary care team, and (5) Ensure that high-quality primary care is implemented in the United States. Fortunately, and perhaps as a result of the NASEM report, more federal and state policymakers are paying attention to primary care. We see a new focus on primary care at the US Department of Health and Human Services37 and more states tracking primary care spending or setting primary care targets to increase primary care investment and strengthening access to team-based care.38 Yet, the work needed to meet the objectives outlined in the NASEM report is far from complete.
The NASEM report authors recommended the development of a primary care scorecard to track progress toward meeting its objectives, leading to the first scorecard report and dashboard in 2023. Using the NASEM report objectives as a framework and examining trends in the primary care workforce, primary care training, and investment in primary care services and primary care research, this year’s Scorecard identifies five factors contributing to the country’s worsening access to primary care. This year, we also offer more robust state specific performance data in the Scorecard data dashboard. While this report profiles some initiatives where primary care policy is being done right, it underscores the need to implement the NASEM policy solutions that will address the primary care access crisis at the scale needed.
I liked my primary care doctor but because I had to wait so long to get an appointment with her, when I was sick, I would go to urgent care. I would only see her for my yearly check-up. During COVID, I got several messages from my doctor that said she was limiting services and adding fees for things like timely prescription refills to keep herself in business. Eventually, I got a letter from her practice saying she was going into concierge medicine. You could get same-day appointments, longer appointments that started on time, and reach her by phone, email, or text. But it was $2,000 a year to join the program, so I opted out and don’t currently have a primary care doctor.Jennifer Dunham, New York City
I liked my primary care doctor but because I had to wait so long to get an appointment with her, when I was sick, I would go to urgent care. I would only see her for my yearly check-up. During COVID, I got several messages from my doctor that said she was limiting services and adding fees for things like timely prescription refills to keep herself in business. Eventually, I got a letter from her practice saying she was going into concierge medicine. You could get same-day appointments, longer appointments that started on time, and reach her by phone, email, or text. But it was $2,000 a year to join the program, so I opted out and don’t currently have a primary care doctor.
