The Path to Health Care for All Starts with Community-Based Primary Care

This is the first in a two-part series exploring the path to affordable health care for all through practical, proven intermediate steps.

Part 1: Building the Foundation of a Sustainable Health Care System

America's health care system faces seemingly insurmountable challenges – skyrocketing costs, uneven access, and middling outcomes despite enormous spending. Yet across the country, communities are proving that transformation is possible by starting small and building from the ground up. As we'll explore in this two-part series, the road to essential health care coverage becomes much more achievable with two strategic stops along the way: universal primary care and removing extreme waste.

This first article focuses on community-based primary care – the bedrock of any high-functioning health care system and, remarkably, the only area of medicine with unequivocal evidence that it pays for itself many times over.

History Shows Us the Way: Community Solutions First

America's most essential public services weren't created through sweeping federal legislation or corporate initiatives. They began as community solutions, developed by neighbors solving local problems with practical approaches. While politicians and pundits insist that transforming health care requires massive top-down reform, Dr. Michael Fine reveals a compelling alternative path through his work in Scituate, Rhode Island.

In his book "Health Care Revolt," Dr. Fine writes:

"The health care reform efforts of 1993 and 2009-2010 were run by large national organizations that used orthodox processes to change the way the federal government deals with health care. Politics, it is said, is the art of the possible, and the result that was finally achieved in 2010 (which more or less got the reform that was designed in 1993 by a bipartisan group of senators) is likely all that is possible using the legislative processes of the federal government. And that wasn't good enough."

This pattern of grassroots innovation paving the way for systemic change serves as a blueprint for transforming health care. History shows that transformative systems often begin locally. Public education, fire protection, water systems, and mail delivery all originated as community-driven initiatives, with local groups designing solutions tailored to their needs. The most accountable organizations are those rooted in their communities, where proximity fosters both responsibility and responsiveness.

Dr. Fine continues:

"Public education, the police, fire protection, public water systems, public sanitation, and even the U.S. mail all started the same way. They started with local efforts—with communities designing solutions for themselves. Some communities built local schools. Others created police departments. Still others created different versions of fire protection. Each used a different way of organizing the services and created different ways of spreading the cost."

Our experience suggests the road to health care for all can be smoother with intermediate stops like:

• Community-based primary care – The only area of medicine with unequivocal evidence that it pays for itself many times over. It's reasonably affordable and any shortages can be addressed with creativity.

The Primary Care Paradox

As someone who has spent decades examining health care transformation, I've seen the same story play out repeatedly: we discuss primary care's importance while systematically undermining it. While doing research for my book, "The Opioid Crisis Wake-up Call," I realized that nothing created more fertile ground for the opioid crisis than our devastated primary care infrastructure – a byproduct of catastrophically dysfunctional misaligned incentives.

Let me be blunt: primary care in America is broken. As primary care innovator Dr. Douglas Eby of Southcentral Foundation puts it: "Primary care must change. It is the most failed part of the medical system, and I'm tired of hearing primary care people complain about being victims. 'Woe is us — we don't have status, we don't have privilege, we're paid terribly, everyone dumps on us, everyone blames us.' Well, yes, and… so what? The customer has no power and control in changing health care. If the system is going to change, the people who run the longitudinal platform called primary care have to change that platform themselves."

This failing system creates cascading problems: physicians burning out, patients unable to access care, and astronomical costs as preventable conditions worsen and require expensive interventions. Yet paradoxically, primary care also represents our greatest opportunity for transformation.

What Works: Success Stories in Challenging Environments

Southcentral Foundation's Nuka System of Care serves 65,000 Alaska Native people across an area the size of Sweden – including remote villages without even medical assistants. Despite these challenges, they've achieved remarkable results:

• Emergency room utilization reduced by 50%

• Hospital admissions decreased by 53%

• Specialist utilization reduced by 65%

• Childhood immunization rates at 93%

Their secret? They redesigned primary care from the ground up, creating integrated care teams where every member works at the top of their license. They stopped accepting the status quo and instead built a system based on relationships, cultural respect, and community ownership.

Dr. Eby's message isn't just powerful – it's delivered with the undeniable credibility of someone who transformed health care for Alaska Native people from among the worst outcomes in America to a system widely considered the world's best. Health care leaders from across the globe now travel to Alaska to learn from this model, a testament to what becomes possible when excuses are replaced with action.

As Dr. Eby notes:

“If Alaska Native people can change the bureaucracy and culture of a system that began when Native Americans healthcare was a part of the Department of War, then any bureaucracy can change.”

Another remarkable example comes from Orlando, Florida, where hotel owner Harris Rosen created a health care transformation that rippled through an entire community:

Harris Rosen, a hotel owner in Orlando, faced skyrocketing health care costs that threatened his business and employees' wellbeing. Rather than accepting annual increases or shifting costs to employees, he took direct control of health care delivery by converting part of his accounting office into a medical center with one part-time doctor.

This modest beginning evolved into a comprehensive health care system that delivers:

• Health care costs at about half the national average despite being based in Florida where 40% of the most pricing gouging hospitals are based

• Outstanding maternal outcomes despite 56% of pregnancies being categorized as high risk

• Employee turnover reduced from over 60% to the low teens

• Workers' compensation costs decreased by 50%

The rewards of RosenCare's transformation became evident quickly and grew more impressive over time. The financial impact was dramatic. Health care costs dropped to approximately half of the national average – creating what would later be called the "Health Rosetta Dividend." While other employers faced annual double-digit increases, Rosen's per-employee costs ran 55% below industry averages, translating to a cumulative $540 million savings for their organization of more than 5,000 people. Single coverage for a majority of employees cost just $16.66 per week for a comprehensive package. This dividend proved that recovering health care waste could generate enough funding not just for better care, but for investments that would transform entire communities.

The Rosen success story demonstrates how effective primary care reaches far beyond health outcomes. The "Health Rosetta Dividend" – money saved through better health care management – was reinvested in education and community development. They not only fully fund their employees and their children’s college education, they have adopted two neighborhoods fully funding daycare, pre-K, after school programs and college education for any student who graduates from high school. 

The impact on individual lives proved particularly profound through the scholarship program's design. By covering all expenses – tuition, books, room and board – graduates completed their degrees debt-free. This financial freedom enabled many to pursue advanced degrees, creating a new professional class within the community. The statistics tell a remarkable story: high school graduation rates rose from abysmal to nearly 100%, college graduation rates soared to 78%, and crime dropped by 80%.

The return on investment proved extraordinary. Research by economist Lance Lochner found that for every dollar invested in the program, seven dollars returned to society through reduced crime, increased earnings, and other benefits. The approximately $13 million invested over 26 years has generated an estimated $91 million in societal benefit.

A third success story emerges from the industrial Midwest:

In Ashtabula County, Ohio – one of the state's poorest regions and a medical desert without a single independent primary care physician – benefits advisor Bryce Heinbaugh helped implement a transformation that has become a model for communities nationwide.

Starting with Ashtabula Area City Schools, they built a Community Owned Health Plan that:

• Saved $2.4 million in health care spend in the first year for their small school district with 300 staff members

• Eliminated financial barriers to care

• Attracted high-quality clinicians to a previously underserved area (less than 30% per capita physicians in their county)

• Kept health care dollars in the local economy

The model spread to the City of Ashtabula, the county government, and private employers, creating what amounts to a significant raise for thousands of employees by eliminating out-of-pocket costs while improving care quality.

These diverse success stories demonstrate that primary care transformation is possible in any setting - from Alaska's remote villages to Florida's tourist economy to Ohio's industrial communities. The common thread is a willingness to reimagine health care delivery from the ground up.

The Blueprint: Principles for Primary Care Transformation

What makes these primary care transformations successful? Several key principles emerge:

These diverse success stories share common principles that form the Health Rosetta blueprint. While this blueprint encompasses multiple components, primary care transformation stands as the most foundational element. These principles can be applied anywhere:

1. Reimagine Primary Care Delivery: Build relationship-based care models with integrated teams where every member works at the top of their license. Give clinicians time to actually care for people instead of rushing through visits.

2. Remove Financial Barriers: Eliminate deductibles and copays for high-value care. Make preventive services and chronic disease management easily accessible without financial penalties.

3. Integrate Behavioral Health: Embed behavioral health professionals directly in primary care settings, making mental health support immediately available when needed.

4. Build Direct Relationships: Establish direct contracts with high-quality specialists and facilities based on transparent pricing and quality metrics, bypassing price-gouging enabling PPO networks.

5. Create Navigation Support: Implement nurse navigation programs that guide patients to appropriate, high-quality care while providing ongoing support.

6. Implement Transparent Pharmacy Benefits: Eliminate PBM markup and make generic medications affordable or free, keeping pharmacy dollars in the community.

7. Invest in Prevention: Focus resources on preventing health care disasters rather than just responding to them.

8. Engage the Community: Build health care systems owned by and accountable to the communities they serve.

These principles work in diverse settings – from tribal health systems to school districts, from rural communities to urban centers, from public sector organizations to private businesses.

Community-Based Primary Care: A Step Toward Health Care for All

For those committed to achieving health care for all Americans, starting with community-based primary care offers strategic advantages. It's more politically achievable, economically sustainable, and creates immediate benefits that build momentum for broader reform.

Dr. Fine shares his own community's success story:

"Fifteen years ago, Scituate became the first community in the U.S. to guarantee all its residents access to primary medical and dental care. We got a little foundation money to get that started, and now the very Republican town government contributes every year to make sure every person in Scituate has health care. We are one of the best-vaccinated places in the county. People get flu shots when they go to vote and when they walk around the streets doing their Christmas shopping in December. Our kids get sports physicals in the fall at the school."

As demonstrated in Scituate, Rhode Island, even politically conservative communities can embrace universal primary care when they see the concrete benefits. It becomes a practical matter of community wellbeing rather than an ideological battle.

But What About the "Primary Care Shortage"?

A common objection to universal primary care is the perceived shortage of primary care physicians. However, this reflects a failure of imagination more than reality:

The conventional wisdom says we face a primary care physician shortage. I say we face a shortage of imagination and action orientation.

Consider what passes for "primary care" today:

• Appointments often less than 10 minutes

• Long waits to get seen

• Physicians spending two hours on insurance bureaucracy for every hour of patient time

• Primary care physicians reduced to "referralogists" – trapped in a system that rewards them for shuffling patients to specialists and writing prescriptions rather than healing, driving both physician burnout and health care costs to crisis levels

This isn't primary care – it's cattle care.

When we reimagine primary care delivery using team-based models and removing administrative burdens, we can dramatically expand capacity while improving job satisfaction for clinicians. In the Nuka care model, all of these roles are critical to their primary care model – the integrated care team in the Nuka model of care include a PCP (MDs as well as NP/PAs), Nurse Care Manager, Case Management Support, Certified Medical Assistants, Behaviorists, Dietitians, Pharmacist, Nurse Midwife, Coverage NP/PA/CM's, Psych, Codes & data entry, and front desk. This has been supported by an extensive workforce development effort in a very challenging setting.

As noted in my recent article "Primary Care Transformation: Stop Making Excuses and Start Making Progress," The primary care crisis isn't about a shortage of physicians – it's about a shortage of imagination and courage. We've proven that transformation is possible even in the most challenging circumstances. Between making primary care appealing again and team-based care models that have a wide array of health care professionals, clinicians will flood in to fill the gap.

Advanced Primary Care Models: Multiple Paths to Success

The success stories highlighted above represent different models of Advanced Primary Care (APC), each tailored to their specific community needs:

Advanced Primary Care (APC) refers to innovative primary care delivery models that aim to improve health outcomes and reduce costs by fundamentally changing how primary care is practiced and financed. These models include Direct Primary Care (DPC) (membership-based practices that bypass traditional insurance), onsite and nearsite employer clinics (employer or union-sponsored health centers for workers and families), and value-based primary care groups (practices taking financial risk for patient outcomes, often in Medicare Advantage or accountable care arrangements). All APC models emphasize enhanced access, prevention, and care coordination, departing from the high-volume fee-for-service status quo.

Why APC? Rising health care costs and poor outcomes in the U.S. have driven employers, providers, and policymakers to explore better primary care. By investing more time and resources up front in primary care – longer visits, team-based care (including health coaches, care managers, etc.), and data-driven population health management – APC models seek to keep patients healthier and avoid expensive downstream care.

Outside the U.S., countries such as Denmark have invested heavily in primary care, where over 90% of health issues can be fully addressed in a primary care setting. This approach has eliminated the need for 70% of hospital beds while delivering better, more proactive care and saving a tremendous sum of money.

Different communities will naturally develop different models based on their needs, resources, and preferences. The key is allowing this organic community innovation to flourish, rather than insisting on one-size-fits-all solutions.

Building the Movement: From Local to National

Community-based primary care represents a crucial stepping stone toward comprehensive health care reform. By starting locally and proving what works, we create momentum that can eventually lead to national transformation.

Dr. Fine offers this approach to building a health care movement:

"To create the Movement for Health Care in America, we can all start where we live.

I live in Scituate, Rhode Island, a little exurban town of ten thousand, about fifteen miles from the city, which for us is Providence, Rhode Island. Twenty years ago, I started talking and listening and finding people who thought there was something we could do together. I gave them the numbers and then got out of the way while people worked together."

This community-centered approach aligns with what Kate Raworth (Doughnut Economics) suggests: we must create bridges from our present to our future. These bridges can build momentum and prove their efficacy.

The Path Forward

As we look toward achieving health care for all, community-based primary care offers a practical first step that addresses immediate needs while building toward more comprehensive reform. In our next article, we'll examine the second critical stop on the journey: removing extreme waste from the health care system. Organizations from the National Academy of Medicine to PwC state that 30-50% of health care spending is waste. We've created the first objective scoring of commercial health plans that prescribes how to find opportunities to improve benefits while freeing up resources for higher and better uses. It's rare when we haven't found at least 10-20% savings – frequently more as Marilyn Bartlett's work with the Montana state employee health plan demonstrated. It’s common for these modern health plans built around advanced primary care and avoiding health care’s waste to cost 40% less per capita. 

Together, these two strategic interventions – community-based primary care and waste elimination - create a path to health care for all that is politically achievable and economically sustainable.

Dr. Fine concludes with this hopeful message:

"Other communities can and will do the same. It will look a little different in each place. In some places it will be stronger and in others weaker, but that diversity is good for us all, because that is how we learn."

By starting where we are with the resources we have, we can build a health care system that truly serves all Americans. The journey to health care for all begins with community-based primary care.

This is the first in a two-part series exploring the path to health care for all through practical, proven intermediate steps. In Part 2, we'll examine how removing extreme waste from the health care system can create resources for broader coverage while improving care

Dave Chase is a co-founder and CEO of Health Rosetta. Prior to Health Rosetta, he co-founded Avado, which was acquired by and integrated into WebMD/Medscape; founded Microsoft’s 28,000 partner $30 billion health care ecosystem; and was a consultant with Accenture’s health care practice..