How Investing in Primary Care Can Advance Equity – California Health Care Foundation

When properly 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, with the result that an impoverished workforce struggles to provide care in a weakened infrastructure. The first National Primary Care Scorecard released in February underlines this reality and demonstrates that our current primary care policies do not adequately support 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 enacting legislation to increase investment in primary care. A new CHCF-sponsored report summarizes decades of research demonstrating the link between primary care and improved health equity. In this report, we argue that more needs to be done differently to rebuild the foundations of our healthcare system fairly.

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 public good
• Embrace the diversity of primary care practice settings and invest resources as needed with the intentional goal of reducing health and social inequalities
• Proactively apply the principles of fairness and justice to all decisions
• Create accountability for action
• Achieving such a paradigm shift is a political challenge. What will policy makers and other decision makers need to consider when implementing these policies?

Principles of politics

Primary care access, quality and resources vary widely between communities. These disparities reflect decades of diverse investment and fall most heavily on underserved communities, including those at highest risk of health inequalities, such as Black, American Indian, and Alaska Native populations. More investment in primary care is needed. Any future programs and investments must promote equity in primary care. Specific solutions will (and should) vary from state to state, but here are four general policy principles:

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

Application of these principles

Innovative primary care investment and policies are needed in communities across the nation to forge a path to health equity, and a one-size-fits-all approach will not be enough. Strengthening primary care in a way that ensures equity for patients, communities and health care providers will require a radical refocusing of payments and policies.

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

• Could tax policy be used to provide relief to struggling independent practices or provide incentives for healthcare practices and systems to partner with community-based organizations to address health inequalities?
• What kinds of new partnerships are possible between various levels of government, including municipalities, counties, states, and the federal government?
• We can leverage public funds and regulations (for example, through state Medicaid agencies) to align primary care capacity, systems, and improvement efforts with broader place-based public health and community-led efforts to promote population health and health equity?

Furthermore, 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 evaluating needs, service improvement and accountability
• Funding Networks of community-based organizations, hubs that can support contracts between community organizations and healthcare professionals

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.

This article was originally published by the Milbank Memorial Fund and is reprinted with permission.