As we entered medical school, we were starry-eyed and hopeful about becoming primary care physicians. We romanticized building relationships with patients, providing high quality health care, serving our communities, and removing obstacles patients face when seeking care.

However, rotation after rotation, we were bombarded with discouragement.

“Being a primary care physician isn’t what it used to be.”

“You can’t get the support you need to take good care of patients anymore.”

“Don’t do it.”

Comments like these are frequently heard by medical students, even from primary care physicians (PCPs). The obstacles that PCPs face in delivering care are only exceeded by the obstacles that patients face in accessing that care. This is inevitable in a health care system that too often values profit over people.

However, there is a solution that addresses roadblocks for both PCPs and patients — increasing primary care investment — which just might inspire more medical students to pursue primary care.

The state of primary care

Primary care is, and has been, in crisis.

Nationally, the proportion of the physician workforce in adult primary care has declined and now sits at just 25 percent. The reasons are familiar. Culprits include an older workforce, earlier retirement, burnout, poor primary care practice support, and lower compensation relative to other specialties. Even before the COVID-19 pandemic, a study from the Journal of the American Board of Family Medicine found that close to three in four PCPs reported burnout. It is no wonder that by 2036, the U.S. will face a shortage of approximately 68,000 full-time equivalent PCPs.

These workforce-related consequences, stemming from poor investment in primary care, harm patients and increase health inequities. Between 2012 and 2021, the share of children not having a regular source of care saw a 36 percent jump, with adults seeing a 21 percent jump on this metric. In the U.S., about 100 million people do not have regular access to primary care.

A few states have recognized this urgency. Delaware requires that Qualified Health Plans engage in quality improvement workgroups by standardizing strategies, activities, metrics, and payment structures to enhance health outcomes and support medical home models. Rhode Island requires carriers to provide practice support payments that promote and sustain Patient-Centered Medical Home (PCMH) designation, offering both infrastructure and care management payments to eligible practices. Oregon has promoted integrated behavioral health practices by mandating Coordinated Care Organizations (CCOs) to implement Patient-Centered Primary Care Homes (PCPCHs).

Even Massachusetts (MA), often seen as a health reform leader, faces severe primary care challenges. One of every three MA PCPs is over 60 years old. The state has also seen an increasing percentage of PCPs leaving primary care, coupled with a low rate of graduating medical students entering the field. Between 2023–2025, per an informal survey of medical schools in Massachusetts, only 5 percent of graduating medical students in MA planned to enter family medicine. Yet, MA might have a solution: primary care investment.

Why invest in primary care?

Strong primary care systems improve health outcomes, increase access to care, and advance equity, all while lowering per capita health costs. And yet, while 35 percent of health care visits are for primary care, it only accounts for 5–7 percent of health care spending. A California Health Care Foundation study found that increased primary care spending was associated with enhanced care quality and patient experience, with reduced total care costs, hospital use, and emergency department use.

This crisis cannot be addressed with continued incremental reforms when existing primary care infrastructure is crumbling. The only way we can shift the values of our health care system from profit to health and equity is through legislation. If we want something different, we have to do something different — something fundamentally different.

Primary care for YOU: The MA primary care investment legislative proposal

Primary Care For You (PC4YOU), a bill originally introduced by Senator Cindy Friedman, Co-Chair of the Joint Committee on Health Care Financing in MA, would double state primary care investment and would be a model for primary care transformation.

First, PC4YOU pays for value, instead of volume, in order to better align incentives to promote health for patients and communities. PCPs across the state would no longer be paid per patient visit, but instead be reimbursed per patient. This shift away from fee-for-service and towards value-based care may also be helpful in reducing burnout in primary care.

Second, MA insurers would be required to dedicate 15 percent of health care spending to primary care services by 2029. Mandating this investment will lead to enhanced primary care infrastructure. For example, Rhode Island (RI) issued a similar mandate to commercial insurers and saw increased investments in spaces such as health technology, Patient-Centered Medical Homes, and loan forgiveness programs — likely aiding in stabilizing and strengthening the RI primary care workforce.

Third, primary care practices would receive incentives for innovation. PCPs would be financially supported in providing patients with valuable services such as mental health clinicians embedded in the practice, addiction care, increased availability on evenings/weekends, community health workers, home care, telehealth, group visits, and longer visits. PC4YOU would also enable primary care to achieve its mission of promoting health equity. PCPs would be better supported to address systemic and societal drivers of disease, such as challenges with housing, transportation, and food insecurity.

Conclusion

The primary care triple superpower of better health, improved equity, and decreased cost is amplified by legislation that increases primary care investment. PC4YOU has the power to transform primary care delivery in Massachusetts and serve as a national model.

If such legislation were to pass, medical students may finally see primary care as a field supported with the resources it needs to thrive, and thus may be more persuaded to consider such a career. Without legislation that properly invests in primary care, it is not difficult to start imagining a world where primary care is transactional; and relationship-based primary care is a nostalgic memory. This evolution would yield a health care system that is more expensive, less equitable, and one that delivers poorer health to us all.

​​Vineeth Amba and Archita Goyal are medical students. Wayne Altman is a family physician.