Primary Care Investment

Greater investment in primary care is associated with lower costs, higher patient satisfaction, fewer hospitalizations and emergency department visits, and lower mortality. Despite current high levels of healthcare spending in the United States, the proportion spent on primary care is insufficient. A shift in resources to support greater access to comprehensive, coordinated primary care is imperative to achieving a stronger, higher-performing healthcare system.

Underinvestment in primary care gives rise to patient access and workforce issues. A significant financial incentive for physicians and other clinicians to choose other areas of specialty undermines primary care. 

State Legislation Map as of February 2020


State Report Map as of February 2020

Maps provided by the Milbank Memorial Fund


States Are Leading the Way:

There are a few states at the forefront of the effort to prioritize advanced primary care through better measurement and increased investment. 



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In October 2020, Pennsylvania's Gov. Tom Wolf signed Executive Order number 2020-05, which establishes the Interagency Health Reform Council to "to evaluate the potential alignment of Commonwealth health care payment and delivery systems to provide efficient, whole-person health care that also contains costs, reduces disparities, and achieves better health outcomes for Pennsylvanians." Part of the Council's responsibilities include setting spending targets for primary care and behavioral health to promote whole-person care in the state. The first report of health care reform recommendations is to be submitted by December 31, 2020.


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In January 2020, Governor Lamont issues Executive Order No. 5 which Directs the Office of Health Strategy to establish statewide healthcare cost growth and quality benchmarks and a primary care spending target of 10% by  calendar year 2025.


In May 2019 Colorado passed legislation HB19-1233 Investments In Primary Care To Reduce Health Costs setting targets for investment in primary care and establishing a primary care payment reform collaborative in the division of insurance in the department of regulatory agencies.

In 2018, Colorado primary care stakeholders came together in support of HB18-1365 – Primary Care Infrastructure Creation. The legislation would have created a primary care payment reform collaborative and reporting on primary care spending by an all-payer health claims database. While significant progress was made, the legislation did not pass in 2018.


In May 2019, Vermont passed legislation increasing the proportion of healthcare spending allocated to primary care. The legislation, S.53, and H.89 propose to require the Green Mountain Care Board to determine the proportion of healthcare spending currently allocated to primary care, recommend the proportion that should be allocated to primary care going forward, and project the avoided costs that would likely result if that proportion were achieved.

In 2015, the Primary Care Payment Work Group identified how a capitation payment model for primary care might be implemented in Vermont. The work included significant analysis of primary care spending and recommendations to increase the share of total healthcare expenditures that flow to primary care provides.


In 2019, Washington state appropriated $110,000 for fiscal year 2020 that is provided solely for the office of financial management to determine annual primary care medical expenditures in Washington, by insurance carrier in total and as a percentage of total medical expenditure. Where feasible, this determination must also be broken down by relevant characteristics such as whether expenditures were for in-patient or out-patient care, physical or mental health, by type of provider, and by payment mechanism. The determination must be made in consultation with statewide primary care provider organizations using the state's all-payer claims database and other existing data.

West Virginia

In March 2019, West Virginia passed SB 641 creating the Primary Care Support Program to provide technical and organizational assistance to community-based primary care services and report on West Virginia Medicaid primary care expenditures as a percentage of total West Virginia Medicaid expenditures. 


In August 2019, Delaware's State Assembly passed an act that expands the membership of the Primary Care Reform Collaborative and creates an Office of Value-Based Health Care Delivery in the Department of Insurance to reduce health care costs by increasing the availability of high quality, cost-efficient health insurance products that have stable, predictable, and affordable rates.  The Office of Value-Based Health Care Delivery will work with the Primary Care Reform Collaborative and the State benchmarking process. 

In May 2019, introduced SB 116 to create the Office of Value-Based Health Care Delivery in the Department of Insurance to reduce health care costs by increasing the availability of high quality, cost-efficient health insurance products that have stable, predictable, and affordable rates.

In January 2019, Delaware’s Primary Care Reform Collaborative (Collaborative) released recommendations to invest more in primary care to meet the medical, behavioral, and social determinants of health of Delaware’s diverse patient population. These recommendations, if adopted, have the potential to help transform the healthcare system in Delaware and enhance value.

In 2018, created a Primary Care Reform Collaborative that will issue written recommendations by January 2019 including whether 12% of health care spending should be directed to primary care.


In June 2019, Maine passed legislation called " An Act to Establish Transparency in Primary Health Care Spending," which requires insurers to report primary care expenditures to the Maine Health Data Organization and for the Maine Quality Forum to use this data to report annually to the Department of Health and Human Services and the Legislature, the percentage of total medical expenditures paid for primary care.



In 2017, Oregon’s legislature unanimously passed legislation setting a minimum threshold for all payers - both commercial and public – of at least 12% of total medical expenditures on primary care.

In 2009, Oregon’s legislature established the Patient-Centered Primary Care Home (PCPCH) program and a task force of clinicians, consumers, public health and healthcare delivery experts.

Rhode Island


The state measured and increased its primary care spending from 5.7% in 2008 to 9.1% in 2012. Over this same period, total healthcare expenditures fell 14%

Next in line: 

States that are currently considering bills to address primary care investment. 


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In 2019, the governor of Massachusetts proposed new healthcare legislation that would increase investment in primary care and behavioral health by 30% within three years. A multi-stakeholder advocacy group (MA Primary Care Alliance for Patients) have drafted a proposal concept for legislation that they plan to introduce at a State House Hearing in the near future. 


In January 2019, Hawaii introduced HB 1444 Primary Care Payment Reform Collaborative establishing a task force known as the primary care payment reform collaborative to: a) examine current levels of primary care spending in the state; and b) develop annual recommendations to the legislature to strengthen the primary care system in the state. This bill has now been carried over into the 2020  session for consideration. 

Past Attempts:

Some states have made promising first attempts at legislation that did not move foward.  


February 2019 Missouri’s House of Representatives introduced HB 879 the Primary Care Transparency Act which would establish a primary care payment reform collaborative for the state. The bill was referred to the Committee on Health and Mental Health Policy and a public hearing was hosted on March 11th. While the legislation did not move forward, interest is building. 


In 2018, California primary care stakeholders introduced AB-2895, the Primary Care Spending Transparency Act.  Unfortunately, this legislation was not passed.


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