Primary Care Investment Efforts in States

States are leading the way when it comes to prioritizing advanced primary care. In recent years, several states have pursued legislation or regulations to measure, benchmark - and ultimately increase - levels of investment in primary care. Below is an overview of state actions to-date.

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Leading the Way


In early 2021, a consortium of the six New England states, known as NESCSO, released a first-of-its-kind regional report on levels of primary care investment across the states. The analysis, based on administrative claims data for 7.2 million commercial, Medicaid and Medicare members across Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont, found that spending on primary care averaged 5.5% of overall healthcare costs. While some of the states (Rhode Island, Vermont, Maine and Connecticut) had previously committed to pursuing primary care investment measures through executive action or legislation, the NESCSO effort newly coordinates these states to report on standard measures of primary care to allow for comparisons and regional benchmarking.

In Maine specifically, the legislature is considering “An Act Regarding Targets for Health Plan Investments in Primary Care and Behavioral Health” (LD 1196 ). It will likely be carried over to next year with a stakeholder workgroup working on details over the summer and fall.








In late June 2021, the Delaware House passed a bill that continues recent efforts to strengthen the primary care system in the state by:

  1. Directing the Health Care Commission to monitor compliance with value-based care-delivery models and develop and monitor compliance with alternative payment methods that promote value-based care.
  2. Requiring rate-filings limit aggregate unit price growth for inpatient, outpatient, and other medical services to certain percentage increases over the next 4 years.
  3. Requiring an insurance carrier to spend a certain percentage of its total cost on primary care over the next 4 years.
  4. Requiring the Office of Value-Based Health Care Delivery to establish mandatory minimums for payment innovations, including alternative payment models, and evaluate annually whether primary care spending is increasing in compliance with the established mandatory minimums for payment innovations.

The senate passed the bill in May.

In December 2020, Delaware’s Office of Value-Based Health Care Delivery issued a new report on healthcare affordability standards that includes plans to “more than double primary care spending in the commercial fully insured market by 2025.” The office set a provisional target to increase investments in primary care by 1% to 1.5% of total cost of care each year until 2025, thus increasing primary care’s percentage of total spending from 5% in 2021 to between 9% and 11% by 2025.


In October 2020, Pennsylvania's governor, Tom Wolf (D), signed Executive Order 2020-05, establishing an Interagency Health Reform Council "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 commonwealth. The first report of healthcare reform recommendations was to be submitted by the end of this year, with cost growth benchmarks set by March 2021.


In early May 2021, Sen. Gustavo Rivera, Chair of the Senate Health Committee, and Assembly Member Richard Gottfried, Chair of the Assembly Health Committee, introduced A.7230/S.6534. The legislation would strengthen primary care through increased access to and affordability of care across the state. (See a fuller news release on this development.)






  • In 2019, Washington appropriated $110,000 for fiscal year 2020 to determine annual primary care expenditures by the state’s insurance carriers. The action was mandated through a budget proviso through the Office of Financial Management, which oversees the state’s APCD. The state’s first report was issued in December 2019.
  • In the 2020 session, the state is now considering legislation (HB 2615) to establish a multi-stakeholder primary care collaborative that would report findings and recommendations to the governor and legislature regarding state spending on primary care.







In May 2019, Colorado passed legislation - HB19-1233 (Investments In Primary Care To Reduce Health Costs) - that set targets for investment in primary care and established a primary care payment reform collaborative in the division of insurance. Proposed legislation in 2018 helped lay the foundation for this step, when primary care stakeholders came together in support of HB18-1365 (Primary Care Infrastructure Creation), which would have created a collaborative and primary care spend reporting.





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 to report on the state’s level of Medicaid investment inprimary care as a percentage of total Medicaid expenditures.






  • In 2017, the Oregone legislature unanimously passed legislation setting a minimum primary care spend threshold for all payers–both commercial and public–of at least 12% of total medical expenditures by 2023. A 2016 study showed that for every additional dollar spent on primary care, savings of $13 was found in other services. (Koller, C. (n.d.). Primary Care Spending Rate-A Lever for Encouraging Investment in Primary Care| NEJM. Retrieved from
  • In 2015, Oregon passed legislation to measure and annually report levels of primary care spend and created a public-private collaborative to develop recommendations for the state’s Health Policy Board.
  • In 2009, the state legislature established the Patient-Centered Primary Care Home (PCPCH) program and a task force of clinicians, consumers, public health and healthcare delivery experts.

Legislation Pending





  • In January 2019, Hawaii introduced HB 1444 to establish a task force known as the primary care payment reform collaborative to:
    • examine current investment levels in primary care
    • develop annual recommendations to the legislature to strengthen the state’s primary care system.
  • That bill has since been carried over to the 2020 session for consideration.


Past Attempts







In February 2019, Missouri’s House of Representatives introduced HB 879, the Primary Care Transparency Act, which would have establisheda 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 the next month. While the bill did not move forward, interest is building in the state.


A bill sponsored by the California Academy of Family Physicians was introduced in 2018: the Primary Care Spending Transparency Act (AB-2895). The bill did not pass, due in part to health plan opposition.

Read the latest state annual reports.


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