A pair of reading glasses, a pen, and a blank Medicare enrollment form. Credit: zimmytws_Adobe Stock.
Josh Omer is a neuroscience and biology double major with a minor in biotechnology, and he is a 2025-26 health care ethics intern at the Markkula Center for Applied Ethics at Santa Clara University. Views are his own.
The United States is facing a health care crisis. Today, America is the “nation with the highest GDP investment in health care in the world,” spending nearly two and a half times more per capita than the average high-income nation. While costly, this investment has positioned America as a global leader in acute care and biotechnology; however, the profit-centered market prioritizes capital toward specialized care while diverting resources away from the primary care system. Primary care accessibility issues have become widespread, with 40 million Americans forgoing routine care and one in five reporting they are unable to see a primary care physician (PCP) when needed. The United States allocates significantly less funding and reimbursement to primary care than to other medical specialties, a trend that has been in decline over the last two decades. In 2022, Medicare and Medicaid spending on primary care accounted for only 3.4% and 4.3% of total health expenditures, respectively, and federal research investments in primary care were 0.31%. Underinvestment in primary care can lead to adverse health outcomes, as reduced access to primary care is strongly associated with lower life expectancy, higher rates of chronic conditions, and increased hospitalizations. This is not only a physician reimbursement problem, but also a structurally ingrained ethical failure that unequally distributes health care disparities and access to care among populations that are already severely disadvantaged.
Medicare’s Reimbursement Policies Contribute Significantly to the Underfunding of Primary Care
As the nation’s largest single-payer program, Medicare plays a foundational role in price setting and service valuation across all specialties in health care. In 1992, Medicare adopted the Resource-Based Value Scale (RBRVS), establishing a value-based system that has been used for the past 30 years. To set prices, Medicare partners with the American Medical Association (AMA) to assign relative value units (RVUs) for each service based on the time required, the service's intensity, and practice expense. RVU assignments are essential for regulating service prices and play an irreplaceable role in shaping the payment system for the entire industry; however, their determination is biased toward specialty procedures, such as surgeries, over cognitive services, including primary care visits and care coordination.
Although RVUs are ultimately set by the Centers for Medicare and Medicaid (CMS), they are heavily dependent on the influence of the AMA’s Relative Value Scale Update Committee (RUC), which is composed of 32 physician advisors from all medical fields. Among the current 32 advisors, the committee is dominated by specialty physicians, with only a few positions allocated to primary care. The underrepresentation of primary care and primary specialties fails to reflect that more than one-quarter of the nation's physicians work in primary care; thus, cognitive services often receive significantly lower RVUs than procedural services, leading to poor reimbursement for PCPs.
The Connection Between Policy, PCP Shortage, and Structural Inequality
Over the past century, the proportion of America’s physicians working in primary care has drastically declined, falling from 75.3% in 1931, 45% in 1957, and 24.4% in 2024. This trend is not accidental but reflects both the bias of America’s profit-based health care system toward lucrative specialty procedures and the corresponding incentive for medical students to enter specialized fields. This financial disparity is clearly reflected through reimbursement rates, as “primary care physicians’ reimbursement per visit averaged $259, compared to $1,092 for gastroenterology,” in 2022, and the average salary of a PCP was nearly a third less than the average salary of specialists. As such, lower compensation and demanding work hours are disincentives for medical students to pursue primary care.
Additionally, the current proportion of actively practicing PCPs indicates the severity of the physician shortage in the United States, given that the ideal ratio of primary care specialties (Family Practice, General Internal Medicine, and Pediatrics) is 50%. This severe PCP shortage has direct quantitative consequences: each additional PCP per 10,000 population is associated with a 5.3% decrease in mortality rate and a 51.5-day increase in life expectancy. The importance of PCP accessibility is further indicated by research that indicates that, “higher amounts of visits to patient-centered care were related to a significantly decreased annual number of visits to specialty providers, less frequent hospitalizations, and fewer laboratory and diagnostic tests.” Thus, inaccessibility leads to a “vicious cycle” in which reduced primary care visits lead to significantly greater downstream health care expenditures, ultimately reducing affordability and accessibility.
Worsening the effects of the already extreme primary care shortage is the fact that physician shortages are unequally distributed geographically and socioeconomically. According to a 2023 study, rural communities bear the brunt of PCP shortages. More than 92% of rural counties in the United States are designated primary care health professional shortage areas (HPSAs); 45% have five or fewer PCPs; and over 199 rural communities have no PCPs. Furthermore, research indicates that numerous non-geographic predictors are associated with limited access to primary care, including public insurance (Medicare and Medicaid), self-pay status, lower socioeconomic status, and elderly populations.
Therefore, Medicare’s price-setting structure creates a current-like effect that has significant downstream consequences on insurance premiums, primary care physician compensation, specialty selection, and workforce shortages, ultimately leading to access disparities.
Ethical Implications of Undervaluing Primary Care
The ethical implications of undervaluing primary care through price-setting mechanisms extend beyond administrative policy and expose flagrant violations of rights-based ethics and virtue ethics.
The clearest ethical violation resulting from underfunding primary care services is the current system’s inability to provide equitable access to health care for vulnerable populations. For decades, data have shown that fewer physicians entering primary care lead to poorer outcomes and reduced accessibility; however, policymakers have failed to respond proportionally to these foreseeable effects. Some federal programs have attempted to improve accessibility, including the Rural Transformation Program, the National Health Service Corps (NHSC), and the Area Health Education Center (AHEC); yet, they function as temporary supports to a larger systemic issue, as 92% of rural counties in the United States still have poor access to primary care. As case studies, countries including Canada and Spain illustrate how policy changes — including the enforcement of the gatekeeper model — have helped balance primary care-to-specialist ratios and ultimately led to uniform improvements in health outcomes across populations. For instance, France began its Médecin Traitant reform, which financially incentivizes individuals to seek specialist referrals through their PCPs, thereby strengthening continuity of care and coordination through primary care. As a result of its strong primary care foundation, France reports remarkably high satisfaction and utilization, as well as continuously rising life expectancies that rank among the top 20 nations in the world. As such, systematic reforms that incentivize primary care are necessary as they promote distributive justice by measurably strengthening health outcomes and increasing equitable access.
The undervaluation of primary care not only results from poor policy design but also from a structural conflict of interest within the RUC committee. Given that the RUC committee is dominated by specialists, a power imbalance is created in which those who benefit from the current system are the ones who design it. The existing power dynamic arising from this unequal distribution of specialists is not ethically justified from a Rawlsian perspective because it facilitates inequality for the least privileged rather than protecting everyone. Opponents of a RUC committee reform argue that inflated RVUs for specialty procedures are justified because they are formulaically determined by procedural time, complexity, and intensity; yet this reasoning fails to address the basic fact that there is a severe under-reimbursement across primary care specialties which stems from the overemphasis of this belief.
More troubling is that the AMA, as the convener, and Congress, as the overseeing authority, both possess the power to override RUC recommendations, yet have not taken action. This raises the question of what the true telos of the AMA is, and how its institutional and authoritative role in medicine determines its moral responsibility. The AMA’s mission statement is “to promote the art and science of medicine and the betterment of public health,” and by supporting the current RUC recommendations, the AMA is morally responsible for the downstream inequities that result from price-setting formulas. Failing to correct the current reimbursement structure is misaligned with the institution’s telos and undermines the practice of cardinal virtues. Prudence requires morality and reason in shaping policy, justice requires honoring the rights and dignity of patients who feel the downstream effects, and temperance calls for restraint when self interest conflicts with public health.
An Initial Solution
This article is not merely an exposure of the crumbling foundation of America’s entire health care system, but a call to action as the infrastructure begins to collapse. Today, more PCPs are leaving the profession than entering it, despite a rapidly increasing demand for primary care. To quantify the severity, the AAMC projects that by 2033, the U.S. will face a shortage of between 21,400 and 55,200 primary care physicians, nearly 10% of our current number of practicing PCPs. These complications are exacerbated by America’s quickly aging population and greater wealth inequality than ever before.
The first necessary step toward urgent reform is to incentivize more medical students to enter primary care. This can be most effectively achieved by narrowing the wage gap between PCPs and specialty physicians and by increasing reimbursement rates for cognitive services. The most direct solution would be for Congress to enact legislation increasing the Medicare Conversion Factor (a dollar amount set by Congress that is multiplied by RVUs to determine Medicare payment rates per CPT) for cognitive services commonly used in primary care. Currently, no re-adjustment metrics have been calculated to evaluate whether they encourage physicians to enter primary care; therefore, this is an essential next step for policymakers seeking to address PCP shortages.
Simultaneously, a tangible solution requires adding institutional-level interventions to encourage entry into primary care specialties and to further support rural physicians. One strategy for achieving this is to expand funding for medical school loan forgiveness programs and the NHSC, specifically for medical students entering primary care fields, and adjust them to account for pay gaps between specialists and PCPs. Additionally, reforming the Medicare-funded Graduate Medical Education (GME) to expand primary care residency slots at a higher rate than specialty residency slots would funnel more medical school graduates into primary care residencies.
Therefore, it is well known that primary care reimbursement is underfunded by both private and public insurers. What is less recognized is that the structural pipeline begins with the RUC’s value scale, which discourages physicians from entering primary care, ultimately contributing to the United States’ severe physician shortage and disproportionately affecting the most underserved populations.