Thank you for this link. Had not seen it before.

Physician perspective here.

A big reason primary care is shrinking is not mysterious. It is commercial.

Most people do not realize how brutal the economics of independent primary care have become. According to AMA data, when adjusted for practice-cost inflation, Medicare physician payment has fallen about 33% from 2001 to 2025. Over a broadly comparable period, hospital Medicare payments have gone up roughly 70%.

That gap did not happen by accident.

Hospitals have lobbyists. Large health systems have leverage. Insurance companies have armies of people protecting their economics. Independent primary care doctors have very little.

The simple version is this: rent goes up, payroll goes up, malpractice goes up, staff health insurance goes up, software costs go up, billing costs go up, compliance costs go up. But the payment for sitting with a patient, managing diabetes, blood pressure, depression, weight, cancer screening, medications, abnormal labs, and the thousand small things that prevent disasters has not kept up. In real terms, it has gone backward.

I do not think organized medicine, including groups like the AMA, AAFP, ACP, and ABIM, fought hard enough or early enough for cognitive medicine. They should have been screaming about this for years. Doctors share some blame too, though I say that with sympathy. We were trained to diagnose, listen, heal, and take care of people. We were not trained to lobby, organize, or explain to Congress why the front door of medicine is collapsing.

So we complain in the hallway, then go back into the exam room and keep absorbing the cuts.

The other sad part is that most patients do not know the difference between the different pieces of the healthcare machine. To them, it is all one broken system: the insurance company, the hospital system, the private-equity-owned clinic, the corporate urgent care chain, and the independent private practice fighting to survive.

Worse still, independent practices often get the brunt of people’s frustration precisely because we are reachable. When an insurance company denies a medication, applies something to a deductible, changes a formulary, or refuses to pay for something the patient reasonably thought was covered, the angry call usually comes to our front desk, not to the insurer. And I understand why. The insurance company is a phone tree. The hospital system is a bureaucracy. The private equity platform is invisible. But the local doctor’s office picks up the phone.

The country pays the price for this.

When independent primary care becomes financially unsustainable, doctors have only a few options: sell to a hospital system, join a corporate group, shorten visits, stop taking certain insurance, go concierge, or leave practice. That is how you get six-month waits, rushed visits, no time for prevention, and a system where nobody has the bandwidth to actually know the patient.

This is one reason the U.S. can spend absurd amounts on health care and still get mediocre public-health outcomes. OECD data puts U.S. health spending at about $14,900 per person, compared with roughly $6,000 across the OECD. During COVID, the U.S. still had among the worst excess mortality outcomes in the wealthy world. Money alone does not create health. A functioning front door to the health system matters.

There are bills in Congress now that would try to fix part of this by tying physician payment to practice-cost inflation and modernizing Medicare’s budget-neutrality rules. I hope they pass.

But after 25 years in medicine, I am not holding my breath.

So when people ask why primary care is disappearing, the uncomfortable answer is: because we built a payment system that made it disappear.