There is a lot of promising activity at the North Carolina General Assembly regarding health care. HB 434 targets the prior-authorization process; SB 316 puts teeth into price-transparency laws; and SB 315 addresses both transparency and prior-authorization in emergency services.

But fixing primary care is another major area that needs work. As anyone (myself included) who has recently attempted to get a primary-care appointment can tell you, if you’re lucky enough to find one that’s taking new patients, it may take months to see the inside of an office.

North Carolina ranks 33rd in available primary care-physicians, and, according to the US Department of Health and Human Services, 92 out of 100 counties qualify as Health Professional Shortage Areas, meaning there are over 3,500 patients for every provider.

This is not just a North Carolina problem though. The United States has uniquely poor primary-care statistics. In a 2024 study of 10 developed nations, the Commonwealth Fund found Americans the least likely to have a longstanding primary-care provider.

Home visits were another area where the US fell way behind, with only 29% of primary-care providers providing the service. Interestingly, half of the nations surveyed had at least 90% of primary-care providers offering home visits. The US also had among the lowest rates of primary-care providers offering services after hours, and only 2% of providers utilized telehealth.

So while the United States is great at maximizing convenience with home delivery and videoconferencing in other markets, it seems health care is not among them.

Why primary care is so important

Part of the reason primary care, especially with convenient services like home visits and telehealth, is so vital is that it prevents unnecessary usage of more-expensive health services — like emergency rooms, ambulances, hospitals, and specialists. Of course, if someone needs these services, we shouldn’t put up any barriers for them. But many who do not have a first contact, especially a trusted primary-care provider, will visit emergency rooms with non-urgent conditions.

This takes high-value health resources away from providers, who pass those costs on to the insurance companies or CMS (the Centers for Medicare and Medicaid Services). Ultimately, it makes health care more expensive for all of us, through higher premiums, copays, and taxes.

A few solutions to this problem could include:

Improving telehealth: In a recent article, my colleague John Hood cited a Cicero Institute study that put North Carolina near the bottom, with a failing grade, on providing telehealth options. As noted above, having more convenient options that keep people out of waiting rooms (especially at ERs and specialists) will help patients access appropriate care faster and make the whole system function more smoothly and affordably.

Expanding practice authority: Advanced-practice nurses, including nurse practitioners, who often provide primary care, could provide relief as well, if their practice authority were expanded. Currently, they have to be supervised by physicians, often in a very cursory way and at a distance. This additional oversight is not required in many other states and doesn’t have a proven benefit.

Join the Interstate Medical Licensure Compact: A bill last session, Senate Bill 324, advocated for North Carolina joining the Interstate Medical Licensure Compact, which allows providers in one state to practice in any other state that agrees to the compact. But it failed to become law, so North Carolina remains outside this compact. This, and other reciprocity agreements with other states, would reduce barriers to potential primary-care providers moving here to help fill the shortage.

Encourage medical schools to increase focus on primary care: A study from Journal of Primary Care & Community Health said East Carolina’s Brody School of Medicine was the state’s medical school with the largest number of students becoming primary-care providers, at 53% of graduates. This shouldn’t be a surprise, since the first sentence of the Brody School’s stated mission is, “To increase the supply of primary care physicians to serve the state.”

Could the UNC System encourage the Brody School to increase their output along these lines and encourage other system schools to do the same, without compromising other practice areas? Increasing the supply of primary-care providers would certainly be one clear way to make this care more available.

More “direct primary care”: For those unfamiliar, direct primary care works like a subscription. You pay your monthly membership fee to a primary-care provider, then when something comes up, you can receive treatment without additional bills or copays if it’s a basic service. Often, because of the efficiency of the model, there is no need for the practice to even have a billing department or much in the way of support staff.

One of the biggest problems for primary-care providers is burnout, with a much-higher rate (51%) than other practice areas. And one cause of this is the high patient load and paperwork burden that comes along with the current paradigm. And while most primary-care providers see 20 to 25 patients a day, DPCs only see an average of six patients a day. Without bureaucracy eating up their time and resources, they can spend more time with patients and still remain viable.

“The Primary Care Enhancement Act of 2025,” a bipartisan US House bill that has been introduced in recent sessions, seeks to expand the use of DPC by directing the IRS to not categorize it as insurance. Some of the same sponsors are trying to expand the use of DPC for Medicaid patients. Since they have a much higher rate of using the ER for non-emergencies, and since studies show that those who use DPC have much lower ER use, giving Medicaid patients access to DPCs could make a big difference.

North Carolina passed something similar to the first idea back in 2020, with a bill that prohibited NCDHHS from defining DPC as insurance. But without a matching federal law, some plans still avoid allowing HSAs to cover DPC. In addition to this potential future use of DPC for Medicaid patients, maybe there are other opportunities to use the efficiency and cost savings of DPC in North Carolina — for state employees possibly?

But overall, figuring out how to solve the complex puzzle of primary care should be a major part of making our state’s health care more accessible and affordable.