Primary Care as a Public Utility: The Case for a Common Fund, JAMA. May 20, 2026, by Song Z, Altman W, Crichlow R, Grumbach K
From the Abstract:
Observations: … State mandates to spend more on primary care through a pluralistic insurance system are subject to payer mix and market power differences in the delivery system, which can lead to inequities in financial support across practices and patient populations. One solution to these challenges is a primary care common fund, which pools primary care spending from public and private purchasers and pays practices directly. This provides conceptual and practical advantages related to patient freedom, state choice, administrative burden reduction, and payment flexibility, which can include alternative payment models reflecting state preferences around non–fee-for-service incentives. Furthermore, this can be done without altering the insurance, payment, and delivery of health care outside of primary care. Precedent exists for such an approach to financing and paying for common goods by states.
Conclusions and Relevance: As people in the US increasingly struggle to find a primary care clinician, state investments in primary care share common challenges. A primary care common fund could help states overcome these challenges by pooling resources and paying for primary care as a public utility—consistent with the vision of primary care as a common good—without disrupting the rest of the health care system.
Comment:
By Jim Kahn, M.D., M.P.H. and Kevin Grumbach, M.D. (article co-author)
This is an intriguing proposal, with the potential to strengthen primary care and in the process demonstrate the feasibility and appeal of broad single payer reform. A few thoughts:
A “public utility” financing model (taken from water and other societal essentials) treats the service it pays for as a public good. This framing is entirely appropriate for primary care, which is essential. With current health insurance chaos, primary care suffers from fractured and insufficient funding, to the detriment of all of us. The public utility model offers universal and simplified coverage, coupled with greater investment, to strengthen primary care.
Importantly, the “public utility” model closely resembles single payer. Specifically, for any given geographic area, everyone relies on a single funding pool that covers all patients for all relevant providers and services, using standard payment rates. From the perspectives of both providers and patients, there is a single payer for primary care. Thus, a primary care “public utility” solution hints at broader system change.
The “public utility” model will be a financial boon for primary care practices. It builds on plans in California and other states to increase the share of health care spending devoted to primary care. And, it will optimize practices’ financial efficiency by eliminating excess “billing and insurance-related” (BIR) administrative costs. We’ve quantified these costs – including contracting, insurance verification, coding, billing, appeals, and myriad other tasks with scores of health insurers. Fully 10% of ambulatory care revenue is *excess* BIR – above what systems with a single payer spend. The single payer under a “public utility” approach will free up that 10%. In addition, with universal coverage, the current roughly 4% of unpaid care (charity care and bad debt) will be paid. Finally, improved coverage for patients may boost utilization by about 8%. Overall, medical practice finances will improve markedly.
There are practical challenges. Most importantly, for primary care-based clinicians with a broader scope of practice, it will be necessary to coordinate parallel financing flows for primary and specialist care. Inpatient hospital and obstetrics services would be paid by health plans directly rather than via the primary care fund. That is, providers would bill the public utility for ambulatory primary care services, and bill insurers for specialty services.
For those of us long trying to convince skeptics of the operational feasibility of single payer in the US, the primary care public utility model will serve as a powerful real-world proof of concept. We expect the public utility approach to enhance the clinical focus and capacity of primary care, by streamlining financial logistics. When that happens, observers — especially doctors – will notice and become more confident of the viability and appeal of single payer. Patients too will be enthusiastic. Thus, a focused real-world implementation could jump-start broad single payer efforts.
While a primary care for all program may build the first floor for a future comprehensive single payer program, it leaves in place the dysfunctional pluralistic health insurance system for non-primary care services, with all the known inequities, coverage gaps, and administrative waste. That said, the model goes well beyond other incremental reforms in offering a systematic restructuring of financing for an imperiled and critical sector – primary care – that is central to a well-functioning health system.
Health care overall should be a public utility: a universally needed service funded through simple publicly coordinated financing. The new proposal is an exciting first step in that direction.
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