JAMA Forum: Progress in Primary Care—From Alma-Ata to Astana

Today, as in 1978, the global community grapples with providing basic, essential health care—especially for the most underserved among us, who are often at the margins of society and the center of health tragedies. In the United States, burgeoning health care costs are increasingly recognized as untenable. At the time of the Alma-Ata Declaration, on a per capita basis, health care spending in constant dollars was $2627 in 1978 and more than tripled to $10 348 in 2016. Of this spending, primary care only receives approximately 7 cents on the dollar, according to one estimate—although part of the problem is that there is no uniform definition of primary care spending, and it is not well-studied.

Some states have taken action to enhance primary care funding. Starting in 2010, Rhode Island required that commercial plans increase spending on primary care by 1% per year, so that by 2014, 10.5% of total spending would be on primary care—through payments supporting quality and efficiency, such as incentives tied to Patient-Centered Medical Home recognition. During this period, Rhode Island was the only state in New England to increase the supply of primary care physicians per capita, while spending by commercial health insurers grew more slowly compared with other states in the region. Oregon and now Delaware have followed suit.

Shifting resource allocation to primary care would help change the core infrastructure of the health system. Fully 11% of adults in the US have gone without care because of cost, but this number is doubled for people at the lower end of the income scale. Uncertainties for community health centers and other safety-net facilities (including public health care systems) exacerbate this situation.

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