AAFP CEO: Our Health Care Crisis is a Primary Care Crisis

Introduction

In his recent testimony before the House Energy and Commerce Health Subcommittee, Dr. R. Shawn Martin, Executive Vice President and CEO of the American Academy of Family Physicians, made a compelling and largely uncontroversial case: the United States is underinvesting in primary care, and that underinvestment is driving both higher costs and worse health outcomes.

He is correct.

Primary care is the most cost-effective component of the healthcare system. It reduces hospitalizations, improves chronic disease management, and lowers total expenditures over time. When patients have a regular source of care, they are healthier, and the system is more efficient.

Dr. Martin accurately diagnoses the problem—and offers a thoughtful set of payment and regulatory reforms. In this hearing, however, his testimony left out a critical dimension of the affordability equation:

We cannot fix primary care without increasing its supply.

Executive Summary

Dr. Martin’s testimony rightly emphasizes that primary care is underfunded and undervalued within the current healthcare system. However, restoring balance requires more than payment reform—it requires expanding the number of primary care physicians available to meet growing demand.

• The United States faces a structural shortage of primary care physicians, driven by policy choices that constrain supply.

• Payment reforms alone will not resolve access challenges if there are not enough physicians to deliver care.

• Federal policy—particularly through Medicare’s role in financing graduate medical education (GME)—plays a decisive role in determining physician supply.

• Expanding primary care capacity is essential to achieving the very cost savings and improved outcomes Dr. Martin describes.

• A comprehensive affordability strategy must therefore include both demand-side reforms (payment, coverage, incentives) and supply-side expansion (training, workforce development, and regulatory flexibility).

  
  

The path forward is not to choose between these approaches, but to recognize that they are mutually reinforcing.

I. Primary Care’s Value Is Clear—And Undisputed

Dr. Martin’s testimony reinforces what decades of health economics research have shown:

Primary care delivers outsized value relative to its cost.

Countries that invest more heavily in primary care consistently achieve:

• Better population health outcomes

• Lower rates of hospitalization and emergency department use

• Lower overall healthcare spending

  
  

Even within the United States, patients with a regular source of primary care experience significantly lower total costs and improved health metrics.

This is not a controversial proposition. It is a settled one.

Yet despite this consensus, primary care accounts for only a small and declining share of total healthcare spending. The system continues to reward episodic, procedure-based interventions over continuous, relationship-based care.

Dr. Martin is right to call for reforms that rebalance these incentives.

But incentives alone cannot produce care where capacity does not exist.

II. Access Is a Function of Supply as Well as Incentives

One of the most striking realities in today’s healthcare system is that a large share of Americans lack a usual source of care.

This is often framed as a failure of affordability or insurance design—and those factors certainly matter.

But it is also, fundamentally, a capacity constraint.

When patients cannot find a primary care physician accepting new patients, or face months-long wait times for appointments, the issue is not merely financial—it is structural. There are simply not enough providers to meet demand.

Health care is not immune to the basic laws of supply and demand. Expanding coverage, reducing cost-sharing, or increasing reimbursement will increase demand for primary care services. But unless supply expands in tandem, those policies risk producing:

• Longer wait times

• Reduced access for vulnerable populations

• Increased provider burnout

• Upward pressure on prices

  
  

In other words, demand-side reforms without supply-side expansion can exacerbate the very problems they are intended to solve.

III. Federal Policy Actively Constrains Physician Supply

The shortage of primary care physicians is not an accident of the market—it is, in significant part, the result of policy choices.

The federal government plays a central role in determining the size and composition of the physician workforce through its financing of graduate medical education (GME), primarily via Medicare.

For decades, the number of federally supported residency slots has been effectively capped. While there have been modest increases in recent years, they have not kept pace with:

• Population growth

• Demographic aging

• The rising burden of chronic disease

  
  

At the same time, the structure of GME funding and physician compensation continues to channel new physicians toward higher-paying specialties rather than primary care.

This creates a predictable outcome: even as policymakers call for greater reliance on primary care, the pipeline of new primary care physicians remains constrained.

Dr. Martin correctly identifies that fewer physicians are choosing primary care. The missing piece is why, and what policy levers are available to change that trajectory.

IV. Payment Reform and Workforce Expansion Must Work Together

To his credit, Dr. Martin offers a series of thoughtful recommendations to improve how primary care is financed, including:

• Providing inflationary updates to physician payments

• Reforming budget neutrality requirements

• Expanding population-based payment models

• Reducing administrative burdens

  
  

These are necessary reforms. They would improve the financial viability of primary care and make the field more attractive to current and future physicians.

But they are not sufficient on their own.

Even a perfectly designed payment system cannot deliver care without a workforce capable of providing it.

A comprehensive strategy must therefore include:

• Expanding GME slots targeted to primary care disciplines

• Aligning training incentives with national health priorities

• Reducing regulatory barriers that limit the scope and efficiency of care delivery

• Encouraging innovative care models that extend the reach of primary care teams

  
  

These steps do not replace payment reform—they amplify it.

V. Affordability Requires a Resource-Based Framework

At its core, the healthcare affordability challenge is a question of resource allocation.

Dr. Martin is right to argue that we are underinvesting in primary care relative to its value. But investment must be understood not only in financial terms, but in real resources:

• Physicians

• Clinical staff

• Time

• Access points

  
  

Without expanding these resources, financial reforms risk redistributing scarcity rather than resolving it.

A system with too few primary care physicians will struggle to deliver timely, preventive care—no matter how well-designed its payment policies may be.

Conversely, a system that expands primary care capacity can:

• Reduce downstream utilization of high-cost services

• Improve management of chronic disease

• Enhance system-wide efficiency

  
  

This is the virtuous cycle that primary care advocates rightly seek to achieve.

But it depends on supply.

Conclusion

Dr. Martin’s testimony provides a valuable and necessary reminder that primary care is central to any serious effort to lower healthcare costs and improve outcomes in the United States.

He is right to call for reforms that better value, support, and prioritize primary care within our healthcare system.

The next step is to build on that foundation by addressing the structural constraints that limit primary care’s reach.

Payment reform can make primary care more sustainable. Regulatory reform can make it more efficient. But only workforce expansion can make it more available.

If policymakers are serious about affordability, they must ensure not only that primary care is properly valued, but that it is sufficiently supplied.

Because in the end, the most cost-effective care in the world cannot reduce costs if patients cannot access it.