U.S. Senators Marsha Blackburn (R-Tenn) and Mark Kelly (D-Ariz.) introduced the Medicaid Primary Care Improvement Act to grant state Medicaid programs the authority to explore and implement direct primary care arrangements for Medicaid beneficiaries. Key features of the Direct Primary Care (DPC) model include predictable costs, improved access, reduced administrative burden, and lower costs.
“Rural residents often experience worse health outcomes and higher hospital utilization compared to urban populations, and 78 of Tennessee’s 95 counties are rural – making it extremely important to improve primary care access for Medicaid recipients in these communities,” said Senator Blackburn. “The Medicaid Primary Care Improvement Act would address disproportionate health care coverage in rural areas by providing states with greater flexibility to address primary care challenges within Medicaid populations.”
“Access to quality primary care is essential for the health and well-being of Arizonans,” said Senator Kelly. “By expanding care options for patients, this bill will allow providers to meaningfully address health needs and improve preventive care.”
BACKGROUND
Primary care providers play a critical role in preventing serious health conditions, reducing emergency room utilization, improving patient outcomes, and potentially lowering overall healthcare costs. Studies consistently show that higher continuity of primary care, where patients maintain a long-term relationship with their primary care physician, leads to fewer hospital admissions.
However, Medicaid populations face unique challenges that exacerbate costs and strain provider capacity, including high emergency room utilization, disproportionate coverage in rural areas, and poorer outcomes in rural communities.
Access to primary care is especially limited in rural, low-income areas. The patient-to-physician ratio in rural areas is just 39.8 physicians per 100,000 people, compared to 53.3 per 100,000 in urban areas. The United States is projected to face a shortage of up to 55,200 primary care physicians by 2032. Expanding access to DPC can help address these workforce and cost challenges by empowering state Medicaid programs to innovate and improve care delivery.
DPC is an innovative health care delivery model that provides patients with unrestricted access to primary care services in exchange for a flat, predictable monthly fee. Unlike traditional fee-for-service models, DPC eliminates third-party billing for most primary care services, allowing physicians to focus on patient care rather than administrative requirements.
While DPC practices are primarily used by privately insured or self-pay patients, there is growing interest in adapting the model for Medicaid beneficiaries to improve access and outcomes, particularly in underserved areas.
MEDICAID PRIMARY CARE ENHANCEMENT ACT
The Medicaid Primary Care Improvement Act would clarify that state Medicaid programs have the authority to explore and implement direct primary care (DPC) arrangements for Medicaid beneficiaries.
The DPC model is a healthcare delivery approach in which patients pay a flat, monthly fee for access to primary care services, enabling predictable costs and potentially improving care coordination and outcomes.
By codifying this authority, the bill seeks to provide states with greater flexibility to address primary care access challenges within Medicaid populations.
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