By Dr. Mark Schwartz

Published: April 30, 2026

Over the past decade, several states, including Rhode Island, Oregon, Colorado and Delaware, have begun experimenting with policies designed to increase the share of health care spending devoted to primary care. These “primary care investment” initiatives require insurers to measure and gradually increase the proportion of health care dollars spent on preventive and coordinated care. The goal is straightforward: strengthen primary care to improve health outcomes while slowing the growth of overall health care spending.

New York is now considering one of the most ambitious versions of this approach. The Primary Care Investment Act, which passed the State Senate in 2025 and is now pending in the Assembly, would require public and private insurers to gradually increase primary care spending until it reaches at least 12.5% of total health care expenditures. The policy is designed not to increase overall spending but to rebalance where health care dollars are spent.

For clinicians working in primary care, the consequences of underinvestment are visible every day.

When Mrs. R came to see me, she was frightened. The 68-year-old retired teacher had just learned she had a mass on her lung after a scan for a stubborn cough. Because we had known each other for years, she trusted me to help her decide what to do next. We reviewed her options, chose a surgeon and made sure her specialists communicated with one another. Two years later, she is cancer-free and back to tutoring at her local library.

Mr. L’s experience was very different. He had no regular physician—only urgent-care visits and specialists treating one problem at a time. When he developed shortness of breath, he cycled through emergency rooms and offices until heart failure and kidney disease brought him to the hospital. His care was fragmented, costly and largely preventable.

These two patients illustrate a structural reality of the U.S. health care system: strong primary care prevents expensive downstream care, while weak primary care allows problems to escalate until hospital-level intervention is required.

Yet primary care remains chronically underfunded. Nationally, less than 6% of health care spending goes to primary care, even as spending on hospitals, specialty services and administrative overhead continues to rise. The result is a system that excels at rescue care but struggles to invest consistently in prevention, early diagnosis and care coordination.

Primary care investment policies attempt to correct this imbalance. Most combine three key elements: standardized measurement of primary care spending across payers, public reporting requirements for insurers and a multi-year target to increase the share of spending devoted to primary care.

In practice, states operationalize these policies through insurance regulation and payment reform. Regulators require insurers to report primary care spending using standardized data—often through all-payer claims databases and rate review filings—while encouraging payment models such as per-member-per-month care management payments or other prospective funding that supports team-based primary care.

Rhode Island provides the clearest early example. In 2010 the state required insurers to increase primary care investment while holding overall spending growth within state benchmarks. According to a 2025 Health Affairs analysis, hospital prices in Rhode Island declined by roughly 9 percent. Emergency department visits and hospital admissions fell, and overall spending grew more slowly than in neighboring states. As more states adopt similar policies, these early results offer an important test of whether shifting spending toward primary care can moderate long-term health care cost growth.

The policy logic is straightforward. Primary care clinicians manage chronic disease, detect illness earlier and coordinate care across multiple providers. When these services are adequately supported, patients receive treatment before conditions worsen into emergencies requiring hospitalization or specialty intervention.

Critics sometimes worry that requiring insurers to increase primary care spending could drive premiums higher. But the intent of these policies is the opposite: to reduce downstream costs by preventing avoidable hospitalizations and emergency visits. By shifting resources upstream into preventive care and chronic disease management, states hope to slow overall health care spending growth.

No single policy will solve the nation’s health care cost problem. Hospital consolidation, pharmaceutical pricing and administrative complexity all play major roles. But strengthening primary care is one of the few interventions consistently associated with better outcomes and lower overall costs.

As more states experiment with primary care investment targets, the results will offer an important test of whether shifting spending upstream—toward prevention, coordination and long-term patient relationships—can improve health outcomes while moderating the growth of health care spending.

Schwartz is a primary care internist in New York state.