The American healthcare system is currently defined by a paradox: it is the most expensive in the world, yet it is failing to provide the most basic level of service—accessible primary care. With only four cents of every healthcare dollar currently allocated to primary care services, the nation is facing a structural crisis that leaves more than one-third of American adults without a regular source of medical guidance.
A provocative new perspective published in JAMA suggests that the current era of incremental reform—characterized by well-intentioned but limited state-level mandates—is insufficient to bridge the widening gap in patient access. Instead, a team of researchers from Harvard, Tufts, Boston University, and UCSF argues for a radical paradigm shift: treating primary care as a public utility, funded through a dedicated "common fund."
The Anatomy of the Crisis: A Chronically Underfunded System
To understand the urgency, one must look at the math. The Health Care Cost Institute (HCCI) reports that primary care receives roughly 4% of total healthcare spending, a figure that has stagnated even as the complexity of patient care has skyrocketed. This financial neglect has manifested in a geographic and professional emergency.
The Workforce Erosion
According to the Association of American Medical Colleges (AAMC), the U.S. now grapples with 7,488 federally designated primary care shortage areas, impacting approximately 74 million citizens. This is not merely a recruitment issue; it is a retention disaster. Burnout, stifling administrative burdens, and a shrinking pipeline of medical students have created a "perfect storm." Data from the 2026 National Residency Match program shows a decline in fill rates for family medicine residency positions—a chilling signal for a system that requires a robust primary care workforce to manage an aging population.
The Failure of Fragmented State Reform
Over the past decade, at least eight states—notably California, Colorado, Massachusetts, and Oregon—have attempted to curb this trend by enacting legislation aimed at increasing the percentage of healthcare spending directed toward primary care. Rhode Island, the pioneer of this movement, managed to nearly double commercial insurer spending on primary care between 2007 and 2023. However, these state-led efforts are hitting a ceiling.
Chronology of the Primary Care Access Crisis
The decline of primary care in the U.S. is not a recent phenomenon, but a decades-long erosion of the physician-patient relationship.
- 1990s–2000s: The rise of managed care and "fee-for-service" models incentivized volume over value. Primary care began to lose its status as the "medical home," as specialists became the primary drivers of healthcare spending.
- 2007: Rhode Island launches its landmark primary care investment initiative, serving as the first true attempt to mandate spending floors for insurers.
- 2010–2020: The Affordable Care Act (ACA) improves insurance coverage, but the supply of primary care providers fails to scale accordingly, leading to the current access bottleneck.
- 2022–2025: Post-pandemic burnout leads to a mass exodus of primary care clinicians. The "Great Resignation" in medicine leaves millions of patients without a primary physician.
- 2026: The JAMA proposal for a "Primary Care Common Fund" is published, signaling a shift in academic consensus from "fix the billing" to "rebuild the foundation."
Why State-Level Fixes Are Hitting a Structural Wall
The researchers behind the JAMA proposal highlight three core obstacles that ensure state-level reforms will likely fail to solve the systemic issue on their own.
1. The Jurisdictional Limit of Federalism
State authority is fundamentally limited by the Employee Retirement Income Security Act (ERISA). Because over 60% of commercially insured workers are in self-insured employer plans, they fall under federal jurisdiction. States have no power to mandate how these plans spend their money. When combined with Medicare and federal employee populations, the majority of a state’s residents are effectively beyond the reach of state-mandated primary care spending floors.
2. The Inequality of Market Power
Fragmented insurance markets mean that a "1% increase" in primary care spending does not yield equal benefits across the board. In a market dominated by high-price, consolidated health systems, a spending mandate often inflates the revenue of already-wealthy systems while doing little to stabilize independent practices or community health centers that serve the most vulnerable, lower-income populations.
3. The Administrative Quagmire
The U.S. system is a patchwork of thousands of different billing requirements, prior authorization rules, and quality reporting metrics. For a small practice, navigating these inconsistent mandates is a full-time job. Rather than creating financial stability, these varied state-by-state mandates often introduce new layers of volatility, making it nearly impossible for practices to plan for the long term.
The Proposal: The Primary Care Common Fund
The JAMA authors propose a compromise: the "Primary Care Common Fund." This model would act as a state-administered pool that collects the primary care portion of spending from commercial insurers, self-insured employers, and Medicaid. These funds would then be disbursed directly to primary care practices.
Key Components of the Common Fund:
- Unified Payer Schedule: By centralizing payments, the model removes the administrative burden of dealing with dozens of different insurance policies.
- Prospective Payment: Moving away from the "fee-for-service" hamster wheel, payments would be tied to the patient panel, providing the predictable revenue needed to invest in staff and technology.
- Market Preservation: The model is intentionally surgical. It only touches the ~5% of healthcare dollars currently going to primary care, leaving the remaining 95% of the system, including specialty and acute care, to operate as it currently does.
Implications for Telehealth and Digital Health
The crisis in in-person primary care has been the primary engine driving the rapid expansion of telehealth. When a patient cannot find a local doctor, they turn to digital platforms and AI-driven triage tools.
The proposed Common Fund could serve as the "missing infrastructure" for virtual care. By stabilizing the finances of primary care practices, it allows them to invest in hybrid workflows—blending in-person visits with virtual check-ins. If the funding model shifts to a prospective, panel-based payment, the economic incentive to force unnecessary in-person office visits vanishes. Clinicians would be rewarded for the health of their panel, whether that health is maintained through a physical exam or a secure video consultation. This would finally allow telehealth to be integrated as a standard tool for continuity of care rather than a standalone, transactional service.
Official Responses and Future Outlook
The proposal has drawn interest from state policymakers in California and Massachusetts, who are already evaluating how such a fund could be integrated into their existing legislative frameworks.
Critics, however, point to the potential for bureaucratic bloat. The creation of a "common fund" requires a massive administrative setup that could be susceptible to political interference. Furthermore, the success of the model rests on the willingness of self-insured employers—the largest cohort of the commercial market—to participate. Without a federal mandate or a massive tax incentive, convincing private employers to surrender control of their healthcare spending will be the primary political hurdle.
"We are at a tipping point," notes the research team. "If we continue to treat primary care as a peripheral service that can be bought on the open market like a commodity, the system will continue to fracture. Treating it as a public utility—an essential infrastructure for the health of the population—is the only way to ensure the doors remain open for the next generation of patients."
As the U.S. moves toward the late 2020s, the debate over the "Common Fund" will likely become a litmus test for the future of American healthcare. Whether it is adopted or rejected, the conversation marks a critical departure from the status quo, signaling that the current model of fragmented, underfunded care is no longer a sustainable way to keep a nation healthy.
