OPINION | Unmet Promises From the State Legislature: The Urgent Need for Primary Care Investment in Washington State

by Anna Morenz, M.D., and Jonathan Staloff, M.D., M.Sc.

Primary care is underfunded in Washington State, with only 4.4—5.6% of total medical expenditures dedicated to primary care according to a recent executive summary presented to the Washington State Legislature by the state Office of Financial Management. This compares to average primary care spending of 14% in other high-income countries. As a result, performance on primary care quality measures in Washington, such as appropriate cancer screening, falls well below the national average. The benefits of robust primary care have been well documented: Primary care not only improves overall life expectancy and reduces all-cause mortality, but also reduces racial health disparities and the adverse effects of income inequality on health. Despite this clear need for enhanced investment in primary care, the 2023 legislative session was a profound disappointment for primary care, and legislators and Gov. Inslee should double down on efforts to improve support of primary care in our state.

For background, the legislature passed Senate Bill 5589 in 2022, which tasked the state's Health Care Cost Transparency Board with measuring primary care expenditures and charting a path to increasing primary care spending to 12% of total healthcare expenditures. Efforts like this are not unique to Washington State, as our neighbor Oregon passed similar legislation years ago requiring that insurers spend at least 12% of total health expenditures on primary care by 2023. With this goal already set in statute by the Washington legislature last year, it is worrisome and disheartening that it chose not to take up proposals for primary care investment this session.

One example of this is the legislature's failure to fund the Washington Multi-Payer Primary Care Transformation Model (PCTM). In 2019, the Washington State Health Care Authority (HCA), the largest purchaser of health care services in the state, convened primary care providers and insurers to collaboratively develop the PCTM, which focuses on advancing primary care in Washington by focusing on paying for comprehensive, integrated, whole-person primary care.

The PCTM would achieve this in two ways. First, it would provide up-front investment to help practices pay for new resources, such as additional staff or data infrastructure, that they would need to advance their capabilities in supporting population health. Several of the practice capabilities the PCTM seeks to invest in center on addressing health-related social needs and building authentic partnerships with patients, families, and community-based organizations — components of primary care sorely needed to advance health equity in our state. Second, as primary care practices experience success in these capabilities, the PCTM would transition payment away from paying set fees for individual services rendered, which are chronically under-reimbursed nationally, and move instead toward population-based payments intended to reflect the value primary care delivers in caring for and keeping patients healthy over time.

The requested $12.8 million in state funds for the fiscal years 2023—2025 was relatively modest — especially in light of the $600 million gap in primary care funding needed to achieve the state's 12% goal — but sadly, the decision package for the PCTM was not included in the governor's proposed budget that was sent to the legislature, and no bill or proviso about supporting PCTM was put forth.

One win for primary care from the 2023 legislative session was the $11.7 million granted in capital funds to The Tubman Center for Health & Freedom to support the construction of their flagship clinic, a Black-led and -owned health center in Seattle. This is the type of investment we need, but much more is needed to support primary care statewide. What we fund is a reflection of what we as a society collectively value. So far the legislature has shown it values talking about primary care; it's time for them to value investing in it.

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Anna Morenz is a board-certified general internist, and Jonathan Staloff is a board-certified family medicine physician. They are both primary care physicians in Seattle, Washington. The views described herein do not reflect the opinions or positions of their employers.

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