‘An enormous amount of churn’: What experts expect primary care practices will face in 2027

Medicaid work-requirement checks and coverage churn will pile new work onto primary care teams that are already stretched thin, a family physician who co-chairs a National Academies committee said.

Health policy experts in a panel discussion added that insurance alone won’t guarantee access. Cost sharing, narrow networks, transportation and an unsteady job market all stand between patients and their primary care teams, they said.

“You know, if you’re dealing with churn and trying to verify people’s access and their coverage and other things, this is going to make it more complicated for our already overburdened primary care teams to to deliver care,” said Alex H. Krist, M.D., M.P.H., professor of family medicine and population health at Virginia Commonwealth University and co-chair of the National Academies of Sciences, Engineering and Medicine (NASEM) Standing Committee on Primary Care.

Krist moderated a Nov. 12 online panel with Andrea A. Anderson, M.D., M.Ed., FAAFP, a professor at the George Washington University School of Medicine and Health Sciences. She and Krist co-chaired the committee that wrote “Ensuring Access to High-Quality Primary Care in the United States,” released Nov. 5. Additional panelists were Matthew Rae, M.P.A., M.P.H., associate director of the Program on the Health Care Marketplace at KFF; Zach Gaumer, M.P.S., vice president of health policy at the Bipartisan Policy Center; and R. Shawn Martin, executive vice president and CEO of the American Academy of Family Physicians (AAFP).

How will churn reach the front desk?

The report was a five-year update to the 2021 landmark report, “Implementing High-Quality Primary Care.” The author committee concluded primary care access has not improved in the last five years since its 2021 landmark report, “Implementing High-Quality Primary Care,” and recent federal policy could make things worse before things get better.

Upcoming work-requirement verification of Medicaid patients “is just going to create an enormous amount of churn,” Martin said.

“I think we anticipate even people that are eligible will just drop out of the program because it becomes very individually labor intensive to enroll yourself or your family in the in the program,” Martin said.

Rae said KFF projects about 14 million people will lose health insurance by 2034 from Medicaid cuts and the expiration of enhanced premium tax credits. The NASEM report cites Congressional Budget Office estimates of 9.1 million to 10 million more uninsured from the Medicaid law, and a 12% drop in Marketplace enrollment this year. Uninsured patients are “about four times less likely to have a usual source of care,” Rae said. By contrast, close to 90% of people with employer-sponsored coverage have one, he said.

Presenting the report, Krist said the coming rise in uninsured patients will increase uncompensated primary care with no matching increase in funding.

“This creates an unfunded mandate for primary care, and it might be a stress for these practices and the socially vulnerable people that they care for,” Krist said. Practices preparing for Jan. 1 can start with three questions at check-in.

Is insurance enough?

Affordable Care Act Marketplace plans are seeing significant increases in average cost sharing in 2026 and 2027, Rae said. About two-thirds of primary care is not preventive, so much of it requires out-of-pocket spending even for insured patients. Network design in Medicare Advantage and the Marketplaces also matters, he said.

Additional difficulties include lack of consistency of coverage from year to year and the fragmentation of the system, Gaumer said. Transportation can send patients elsewhere, he said, and gaps in work could make matters worse.

“The gig economy might disrupt the current system, which we know not to be ideal,” Gaumer said.

Martin raised a newer pressure: artificial intelligence (AI) tools that steer patients to care. He asked: “Where are those people going to go when the AI agent or bot says, go see a doctor?” Patient use of AI may lead to an immediate solution but will not solve health care access problems long term, he said.

Who is the primary care team?

The panel’s talk of payment and access applies to a team, Krist said. That includes “nurse practitioners and physician assistants and the whole care team that’s going to be supporting primary care,” he said.

The report’s third recommendation would require health plans to document how added primary care money is used to strengthen those teams. Anderson summed up that recommendation during her presentation: “So data, data, data.”

Martin said administrative burden should be reframed as restoring physician autonomy. All the checklists on quality measures, all the utilization management stuff should go away, he said.

What would a common fund change?

The report’s top recommendation is a common fund providing universal primary care coverage with no cost sharing. Gaumer said designers would have to decide whether practices are paid fee-for-service under the physician fee schedule or through a bundled payment like the one Federally Qualified Health Centers receive, with geographic adjustments either way.

Insurers now manage costs by steering referrals, using cost sharing and shaping networks, and a common fund could take some of those tools away, Rae said. He also noted that more employers are paying direct primary care practices per member per month for better access, which could pull capacity from patients with other coverage.

Martin backed the concept of a primary care common fund while calling it “obviously not ready for prime time.” Gaumer suggested a state pilot program while coverage comes first. Solving the uninsured problem comes first, calling it “the most pressing problem that we’re facing overall as a country for primary care,” he said.