Primary Care Workforce

New Resources

November 2011

The umbrella term "primary care" includes issues related to health promotion, disease prevention, health maintenance, counseling, patient education and diagnosis and treatment of acute and chronic illnesses in a variety of health care settings such as a doctor’s office, community health center, long-term care facility or home care.  

An effective primary care system provides a team approach to patient care and offers guidance to patients to help them navigate the complex health care system. Ideally this will result in cost-savings by eliminating redundant high cost tests and other services; reducing over-utilization of services and doctor visits, especially emergency department visits; and by increasing patient engagement and compliance to provider instructions such as taking medications as directed and making healthy life-style changes.

Primary health care providers offer services including health promotion, disease prevention, diagnosis and treatment of acute and chronic illnesses, and referral to specialty providers for specific or special needs. Primary health care professionals teams include (but are not limited to): physicians, physician assistants, nurse practitioners, dietician/nutritionists, dentists, social workers, pharmacists, podiatrists, optometrists and health educators.

Percentage of Population Living in a Designated Health Professional Shortage Area, 2011

United States map of Percentage of Population Living in a Designated Health Professional Shortage Area, 2011














Source: Health Resources Service Administration, Data Warehouse, May 2011

Primary Care Workforce: Resources for State Policymakers

In 2009, the national primary care physician shortage was estimated to reach 21,000 by 2015. Fewer medical graduates are selecting primary care as a specialty and existing primary care physicians are retiring or leaving for opportunities in other fields. 

With passage of the Affordable Care Act,[1] it is estimated that an additional 32 million Americans will have insurance coverage by 2019. Starting in 2014, millions of the newly insured will seek medical care in a primary care setting, placing an even greater strain on the primary care workforce. To help states prepare for these changes, NCSL has compiled a list of NCSL educational resources to inform legislators and legislative staff about primarcy care workforce policy options related to the Affordable Care Act.  Below is a list of these resources: 

Affordable Care Act’s Provisions Related to the Primary Care Workforce

Anticipating a nationwide primary care workforce shortage, the Affordable Care Act included many provisions intended to strengthen the current primary care workforce and to build the future workforce. While many provisions will be implemented by stakeholders within the states, policymakers will play a key role in securing the future health workforce for their state.

Many of the provisions in the act are aimed at health care centers and academic institutions. However, by leveraging federal resources with state resources for more effective projects, convening stakeholders, and working with their medical schools, legislators can play an important role in the development and implementation of these programs.

Payment Reform—Research shows that the income gap between primary care and specialist physicians strongly deters health science students from pursuing a career in primary health. The Affordable Care Act provides more support for state policymakers to evaluate and experiment with current payment systems—particularly the Medical Home Model of care—that increase reimbursement  for primary care services such as patient education, disease self-management tools and the coordination of care among many providers.  

  • Increased payments for primary care services under Medicaid. The Affordable Care Act increases Medicaid payments for primary care services to match the required payments for similar services under Medicare in 2013 and 2014, using 100 percent federal funding.  In subsequent years, state Medicaid programs will have to decide whether to maintain the parity.
  • Increased payments for primary care under Medicare. Beginning in 2011, select primary care physicians will get a 10 percent bonus for Medicare services for five years. To qualify for the bonus, 60 percent of their Medicare charges must be for primary care services. 
  • Independent Payment Advisory Board. The Act creates an independent payment advisory board starting in 2014, which will recommend Medicare spending reductions to Congress.  
  • Medicaid Global Payment System. The law authorizes a demonstration project in five states that changes payments to safety-net hospitals from fee-for-services to a global capitated payment model as an incentive for providers to constrain costs.

A Primary Problem (State Legislature Magazine)
Strengthening the Health Care Safety Net (Improving Coverage Series)
Providing Cost-Effective Care Through Medical Homes (Legislative Summit 2010)
Community Health Centers
Medical Homes

Scope of Practice—Controversy over the roles of physicians, advanced practice nurses, and other providers has grown as the demand for primary care providers has increased. Nurse practitioners, for example, are regulated by a patchwork of laws that vary considerably among states. In Alabama they can work only under a physician’s supervision, but in Oregon they can run their own private practices. Increasingly legislatures are examining these regulations and changing the role of primary care providers. The Act aims to extend the role of nurse practitioners in primary care settings and provides $15 million for 10 nurse-managed clinics that train nurses and provide primary health care services in medically underserved communities.

Scope of Practice Legislation Tracking Database
Improving the quality of care: The Continuing Debate over Nurse-Patient Ratios  (State Health Notes)
The Future of Nursing and Primary Care: Implications for States (Legislative Summit 2010)
Community Health Workers (Health Care Reports) 

Workforce pipeline—More than $200 million was included in the 2009 economic stimulus package for health care workforce projects. The Affordable Care Act continues this trend.  The following key provisions address the educational pipeline for the primary care workforce.

  • Academic Assistance and Training Programs. The Personal and Home Care Aide State Training Program and the Nursing Assistant and Home Health Aide Program are designed to create curriculum and training to increase participation in science-based training programs or undergraduate work. 
  • Professional and Post Graduate Training Programs. The Affordable Care Act dedicated more than $200 million to training primary care doctors, nurses, and physician assistants and expanded the National Health Service Corps program by $1.5 billion over five years.
  • Medical Residency Training in Community Health Centers. This program offers payments to eligible health centers to cover the costs of primary care residency training.  

Increasing the Health Care Workforce
Strengthening the Health Care Safety Net Workforce Through Interagency Cooperation, Planning and Policy
Health Reform and Workforce Shortages (Webinar)
Workforce and Access Issues: Part 1 (Health Summit Preconference, Legislative Summit 2010)
Workforce and Access Issues: Part 2 (Health Summit Preconference, Legislative Summit 2010)
Increasing the Health Care Workforce (Legisbrief)

Cultural Competence—The Affordable Care Act has multiple sections that are aimed at increasing the diversity within the primary care workforce. The Act invests in the development and evaluation of culturally competent curricula in provider training over the next five years, and loan repayment preference will be given to individuals who have cultural competency experience.

Disparities in Health
Rural Health Policy Preconference (Spring Forum 2010)  


Financial Assistance for StudentsThe Affordable Care Act extends the financial assistance for health sciences students interested in primary care by providing workforce development grants and tax incentives for those practicing in underserved areas.   A provision in the Act offers students in primary care loan repayment programs a tax incentive by excluding from taxes the value of educational loans that were forgiven or repaid. 


Other resources on the Affordable Care Act and Workforce:

Workforce Provisions in Health Reform (Fact Sheet)
State Implementation of Federal Health Reform (State Activity
States Checking Up on Health Reform: Provider Capacity (Webinar)
Health Reform and Workforce Shortages (Webinar)
Health Care Reform Overview

[1] The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act, which are referred to together as the Affordable Care Act was signed into law in March 2010.