Coverage losses, work requirements and wait-time audits: National Academies flags access risks for practices

In 2027, the practice of primary care may look a lot like the last five: patients who struggle to get in the door, payment that hasn’t kept pace and a new layer of paperwork arriving with Medicaid changes on Jan. 1.

That is the picture painted by “Ensuring Access to High-Quality Primary Care in the United States,” a report released Nov. 5 by the National Academies of Sciences, Engineering and Medicine (NASEM). A committee co-chaired by family physicians Andrea A. Anderson, M.D., M.Ed., and Alex H. Krist, M.D., M.P.H., assessed progress since NASEM’s 2021 report, “Implementing High-Quality Primary Care.” It found that nearly 3 in 10 adults and 1 in 7 children still lack a usual source of care, and that the net effect of recent federal policy is likely to make access worse, mostly by reducing insurance coverage.

The report’s six recommendations are aimed at Congress, federal agencies, states and payers. But several of its findings describe operational pressures practices may feel well before any of those recommendations become policy.

Coverage churn lands at check-in

Beginning Jan. 1, 2027, 44 states must start conditioning Medicaid eligibility for expansion adults and certain waiver enrollees on work or community engagement requirements of 80 hours a month. The report expects the changes to raise uninsurance, citing complex state eligibility processes and “additional burdens on clinicians to document patient exemptions.” CMS has estimated that about 6.4% of otherwise eligible people could lose coverage because of administrative or procedural barriers.

For practices, that means eligibility verification at every visit, not just at enrollment. Physicians Practice has outlined three questions to ask at check-in and how work requirements will land on the front desk.

Marketplace patients face churn of their own. The enhanced Affordable Care Act premium tax credits expired at the end of 2025, and the reconciliation law eliminated automatic reenrollment, so patients must now apply each year with more detail to verify income. The report says that change is expected to hit low-income workers, especially those with fluctuating employment.

The Congressional Budget Office (CBO) estimates cited in the report vary depending on baseline and time frame, from 9.1 million to 10 million more uninsured people by 2034 because of H.R. 1, now Public Law 119-21. Combined with the expired subsidies, CBO projects the uninsured will rise from 26.6 million in 2025 to 37.4 million in 2036, with most of that increase occurring by 2029.

Wait-time standards and secret shoppers

The report highlights 2024 CMS access rules that set a maximum wait of 15 business days for primary care appointments for Medicaid managed care enrollees, validated by annual secret shopper audits. The committee said the standards lack operational guidance and support, both technical and financial, to help practices meet them. With primary care new-patient waits already stretching, practices in Medicaid managed care networks should know where their scheduling stands before an auditor calls.

Payment tools and their limits

The committee counted Advanced Primary Care Management (APCM) as a bright spot. The codes pay prospective monthly amounts that can support care teams. But APCM is limited to original Medicare beneficiaries, about 10% of the U.S. population, and remains subject to Part B cost sharing, which may limit participation. APCM also requires patients to consent to receive services from one primary care clinician in a given month, a step that creates its own workflow.

Most Medicare telehealth flexibilities now run through Dec. 31, 2027, which preserves payment for video and many audio-only primary care visits. That gives practices a year to decide which virtual services to keep if the flexibilities lapse.

Meanwhile, Medicare fee schedule payments to primary care physicians per beneficiary fell from $438 to $420 between 2017 and 2023, and the committee estimated that high-performing team-based primary care requires about $75 per member per month (PMPM) for a general population.

The six recommendations

• Common fund. HHS and Congress should help states pool payer money into common funds that cover primary care for everyone, pay standardized rates and eliminate patient cost sharing, or Congress should consider a federal version run by CMS.
• Reinvestment. Payers should require in contracts with health systems that added primary care payments be reinvested in primary care practices.
• Spending benchmark. State regulators should push primary care to at least 10% of total health care spending and require plans to report how provider organizations use the added money.
• Residency slots. New Medicare-funded graduate medical education slots should favor institutions that produce primary care clinicians, with some slots reserved for primary care trainees.
• Teaching Health Centers. Congress should fund at least twice as many residents and make the funding mandatory.
• Loan relief. Congress should at least double National Health Service Corps (NHSC) funding and shorten the Public Service Loan Forgiveness (PSLF) timeline.

What administrators should watch

If states adopt Recommendation 3, practices may see new reporting tied to added payments, because health plans would have to document how provider organizations use the money to strengthen interprofessional care teams. The report also points to pass-through rules, such as a Massachusetts proposal that would send at least 95% of prospective primary care payments directly to practices. Vermont has enacted a common fund law, and Washington’s insurance commissioner plans to propose one in 2027.

The workforce recommendations matter for recruiting now. The NHSC Loan Repayment Program already offers primary care clinicians up to $75,000 for two years of full-time service in a health professional shortage area. Demand outstrips supply, though: 43% of new NHSC applicants did not receive awards in fiscal year 2020. About 91% of Teaching Health Center graduates enter primary care, which makes those programs a natural hiring pipeline for community practices.

For independent practices weighing the Medicaid changes coming in 2027, the committee’s bottom line is blunt: “Already underresourced primary care practices cannot reasonably absorb the resulting unmet need and uncompensated care without additional support.”