Opinion: The primary care crisis paradox

OpinionFirst Opinion The primary care crisis paradox Primary care, though valuable, is not the only lever that moves population health Manage alerts for this article Email this article Share this article By Christopher P. Childers and Thomas C. TsaiJuly 10, 2026 Childers is a surgical oncologist at the University of Washington and directs the Payment and Outcomes Research Lab. Tsai is a general and gastrointestinal surgeon and medical director for health policy research for the American College of Surgeons. In March, the Medicare Payment Advisory Commission (MedPAC) released its annual report to Congress on Medicare payment policy. The data related to physician payment are clear: By every metric we track, primary care in America is succeeding, and it has been for years. Nearly all Medicare beneficiaries have a primary care provider (PCP). Over three-quarters can see their PCP within two weeks. Patients in rural environments have less trouble finding a PCP and even shorter wait times. Services and spending on evaluation and management codes are increasing, and compensation among PCPs is rising faster than the rest of the field. Yet this runs counter to the pervasive narrative that investing more in primary care is the key to solving the American health care crisis.Advertisement We have all seen the graphs comparing U.S. life expectancy to other developed countries and the graphs showing our spending nearly twice as high as peers. But life expectancy is a crude instrument. When researchers disaggregate the mortality gap between the United States and peer nations, the story that emerges is not one of inadequate primary care access. As a health care system, the U.S. actually performs remarkably well — vaccine rates, cancer screenings, and management of diabetes and hypertension are all above average compared with our peers. Instead, the data show that lower life expectancy is largely driven by external causes: drugs, alcohol, suicide, homicide, and traffic accidents. The conditions driving our excess mortality are chronic, behavioral, and socially determined — and for the tens of millions who are uninsured or underinsured, the causes are compounded by barriers no hospital, clinic, or physician alone can be expected to fix. They are, in the most uncomfortable sense, upstream of the clinic. This is not an argument against primary care. But there is a meaningful difference between primary care being valuable and primary care being the sole lever that moves population health. The available evidence supports the former, not the latter. Countries that outperform us on health outcomes do not have more primary care visits per capita; they have less poverty, less violence, better housing, and more equitable access to the full spectrum of medical care.Advertisement Yet our policy apparatus has not grappled seriously with this distinction. Instead, it has constructed a zero-sum competition at the heart of physician payment — one in which the only path to lifting primary care is to take from every other medical specialty. Because the physician fee schedule must remain budget-neutral, any increase to primary care comes, arithmetically, at the expense of specialty care. This is not a design flaw. It is the design of our broken Medicare payment system. And for more than a decade, advocacy for primary care reimbursement reform has proceeded as though specialists on the other side of that ledger were simply obstacles to overcome, rather than providers whose services patients also need. The consequences are now visible in the MedPAC data, though they have attracted far less attention. Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores show declining patient access to specialists — a finding supported by other surveys and MedPAC’s own focus groups. For patients with complex, multisystem disease, primary care is necessary but not sufficient. Delays in specialist access can mean delayed diagnoses, higher acuity at presentation, and greater resource utilization. There is something deeply paradoxical about a system that celebrates improving primary care access metrics while patients who most need subspecialty evaluation are waiting longer to get it. The patient with well-managed hypertension who cannot access a nephrologist before renal function deteriorates has not been well-served by our investment in primary care. Neither has the patient whose breast cancer demands a coordinated team of surgical, radiation, and medical oncologists but waits months before that team assembles. Each has simply encountered the crisis at a different door. The problem is not that we are investing in primary care. The problem is that we have accepted a false premise — that the only path to a healthier country runs through the primary care office — and built a payment architecture around it that actively undermines access to the broader care patients need.Advertisement Solving the health crisis in the United States will require confronting choices far harder than readjusting a fee schedule: meaningful investment in the social and economic conditions that determine whether people get sick in the first place; an honest accounting of what medicine can and cannot fix; and a payment system that stops treating specialist access as a luxury and starts recognizing it as an essential component of functional health care infrastructure. Primary care is succeeding. That should be good news. The fact that America is no healthier tells us something important — not about primary care, but about how badly we have misdiagnosed the problem. Christopher P. Childers, M.D., Ph.D., is a surgical oncologist at the University of Washington and directs the Payment and Outcomes Research Lab (PAYOR), which studies how payment systems influence physician behavior and patient outcomes. Thomas C. Tsai, M.D., M.P.H., is a general and gastrointestinal surgeon and medical director for health policy research for the American College of Surgeons. He is an associate professor of surgery at Harvard Medical School and co-director of the Healthcare Quality and Outcomes Lab at Harvard T.H. Chan School of Public Health. Letter to the editor Have an opinion on this essay? Submit a letter to the editor. patients, Physicians Submit a correction requestReprints Christopher P. Childers Thomas C. Tsai Newsletter The smartest thinkers in life sciences on what's happening — and what's to come Recommended First Opinion July 9, 2026 Your grandparents are using cannabis. 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