Primary care is the foundation of a health system that works. When primary care is strong, people are diagnosed earlier, chronic conditions are managed before they become crises, and fewer patients end up in emergency rooms with avoidable problems. When it is weak, the opposite happens, and everyone pays through worse health outcomes and higher costs.
Primary care has been underfunded for years in California. As a result, fewer Californians have a regular doctor or care team today than they did a decade ago.
But something significant is happening to turn that around. We represent the state’s largest public purchasers: Medi-Cal, CalPERS, and Covered California. Together, these programs cover nearly 45% of Californians. We are using our collective clout to move primary care from the margins toward the center of the health care system.
This work did not happen overnight. Over the past decade, we have been building toward alignment by establishing primary care spending expectations, developing shared quality frameworks, and creating accountability structures that give health plans and providers clearer, more consistent signals.
The state Office of Health Care Affordability, known as OHCA, was established in 2022 and has set statewide primary care spending benchmarks across payers. This is a meaningful advancement in California’s approach to primary care. Primary care investment is no longer aspirational; it is a measurable expectation with oversight behind it.
Five Conditions for Strengthening Primary Care
With OHCA setting explicit benchmarks, the conversation is no longer about whether to invest in primary care. It is about how to do it effectively, equitably, and on a large scale. Based on our experience as purchasers, five conditions are essential to building this strong foundation.
1. Policy Grounded in How the Market Actually Works
We have spent years building the infrastructure needed to strengthen primary care by embedding requirements into health plan contracts, testing what works, and refining what does not. Because we negotiate directly with health plans, we have been able to keep primary care consistently on the agenda and develop a deep understanding of what drives change.
OHCA inherited this policy groundwork, which made more ambitious goals possible. That groundwork includes embedding primary care priorities into health plan contracts through requirements such as primary care assignment, value-based insurance design, behavioral health integration, and measurement of primary care spending.
Not all approaches worked equally well. Part of our progress has come from testing, refining, and, in some cases, moving away from earlier strategies as implementation experience accumulated.
These strategies have had to account for California’s delivery system, where capitation and delegation to provider organizations are common, and where payment approaches must align with structures such as the Prospective Payment System for community health centers.
2. Alignment That Creates Real Market Power
Our organizations contract with many of the same health plans and have substantial overlap in their provider networks. Rather than operating in silos, we made a deliberate choice to align around shared strategies for our collective members.
That alignment includes similar contract language, implementation timelines, and jointly supported programs such as the Equity and Practice Transformation initiative, which directs payments and technical assistance to small, independent primary care practices.
This alignment has extended beyond us as purchasers. It has influenced measurement frameworks and policy approaches across entities such as the California Department of Managed Health Care and the Integrated Healthcare Association and increasingly aligns with OHCA’s work.
Alignment across purchasers and lines of business is more than useful. It reduces variation, accelerates adoption of best practices, and minimizes administrative burdens for plans and providers alike. Our signal to the market is clear: investment in primary care is not optional.
3. Accountability With High Stakes
California has long had comprehensive public reporting across quality, equity, and patient experience. But transparency alone does not drive meaningful change. Financial incentives can help, but only when the stakes are high enough to matter.
We use a range of approaches to create accountability. Covered California and CalPERS tie a growing share of premium revenue to health plan performance. Medi-Cal uses payment withholds and bonuses to drive better outcomes. OHCA’s statewide primary care investment benchmarks add another layer, reinforcing expectations within a broader framework that includes enforceable targets for cost growth.
Our experience has shown that transparency and small financial incentives, on their own, are not enough. Meaningful change requires high financial stakes paired with a broader accountability framework that reinforces expectations over time.
4. Trust as Implementation Infrastructure
Our experience has surfaced a lesson that does not always make it into policy discussions: Trust among health plans, providers, and the state is critical and fragile. Collaboration is not just an implementation tool; it is a core policy strategy.
When we ask providers to take on financial risk, invest in new care models, and report on new metrics, we are asking them to transform the way they work — and that demands something in return. Providers are more likely to make that commitment when they believe the rules will be stable, the data will be used fairly, and the relationship will be genuinely collaborative rather than purely transactional.
Building and maintaining that trust requires sustained attention through every contract cycle and policy update that follows.
5. Support for Practices Under the Greatest Strain
While OHCA’s benchmarks and our aligned expectations are necessary catalysts, policy and contracting levers must be paired with implementation support. One message has come through clearly in stakeholder meetings and publications on primary care investment: Holding providers accountable only works if they also have the tools, technical assistance, and infrastructure to meet those expectations.
Even when a policy framework is sound, many small and independent practices that serve people covered by Medi-Cal lack the capacity to respond without support. Technical assistance, data infrastructure, and transition funding are prerequisites for equitable implementation. Without them, reform tends to benefit larger, better-resourced systems while leaving under-resourced practices behind.
Where Things Stand
While our progress is substantial, it remains fragile. The share of Californians who have a usual source of care continues to decline. Trust among plans, providers, and state agencies is still being built, and it can easily be damaged by requirements that feel disconnected from operational reality, by data systems that do not yet deliver actionable information, and by the gap between what policy intends and what happens at the practice level.
These five conditions are not items to check off once and consider complete. They are a set of ongoing requirements that demand active maintenance. Alignment can drift when agencies face competing pressures. Accountability can weaken when financial stakes are insufficient. Trust can erode when implementation support fails to materialize. Any one of these failures would be enough to weaken a well-designed policy and turn it into a compliance exercise.
A Rare Moment Worth Protecting
We have assembled something rare in U.S. health care. Rather than a single policy intervention, this is a reinforcing architecture of aligned incentives, expectations, and supports that are backed by public purchasers with the market weight, policy tools, and commitment to move primary care from the margins to the center of the health system. OHCA has added accountability infrastructure that did not previously exist.
What comes of it depends on whether we can sustain alignment, follow through on implementation support, and maintain the trust of the providers and communities this effort is intended to benefit. That is not a small ask. But the alternative is a fragmented, underfunded primary care system that fails the Californians who need it most.
