Primary care should be the foundation. Instead, we made it a gate.

Last week I wrote about why the healthcare system works exactly as designed — for everyone except the patient.

If you want to see that argument made concrete, look at what we’ve done to primary care.

The evidence is unambiguous: robust primary care reduces total spending, improves outcomes, and catches problems before they become expensive crises. It’s the one part of the system structurally aligned with the patient’s interests rather than the chain’s.

So naturally, we’ve systematically underinvested in it.

What we’ve built instead is a system that uses primary care as one of two things: a swinging front door that routes patients to expensive specialists and procedures, or a locked gate that limits access to whatever a plan will approve. Either way, the door you’re offered depends on your ability to spend.

The chronic underinvestment in primary care providers isn’t an oversight. It’s the logical outcome of a spending model that needs patients moving through high-cost interventions. Primary care that actually works — that keeps people stable, healthy, and out of the ER — is a threat to that model.

We talk about fixing healthcare like it’s a renovation project. But you can’t renovate a house with a bad foundation. You can patch the walls indefinitely. The problem is structural.

Making primary care genuinely primary again won’t fix everything. But it’s the right place to start — because it’s the one intervention that would reorient the system around the patient at the bottom of the chain rather than the spend he generates for the top.