By Andrew Jones
CELO COMMUNITY, N.C. — On a 15-degree morning in January, a clinic in the Appalachian Mountains of North Carolina began to fill up with patients.
An older couple in flannel pajamas sat together in the waiting room. A toddler waved as Patricia Hall walked past him, a stethoscope draped over her neck. The family physician waved and smiled back.
But in the privacy of a conference room, her mood shifted. She is often bogged down with paperwork and can’t get patients timely appointments with specialists. She also fears that a health care worker shortage affecting her clinic — and many others across the nation — will only get worse.
Hall’s clinic, the Celo Health Center, is one of seven locations that make up the Mountain Community Health Partnership, which was supposed to receive up to $10 million over the next decade through Making Care Primary, a federal program to improve primary care, especially in rural areas, by providing payments for physicians to address patient needs. Her organization planned to use the money to hire staff, build better connections with local specialists, and fund vehicles to shuttle patients to appointments, according to its CEO, Tim Evans.
Then, in March, clinic administrators received an email during the Department of Government Efficiency’s whirlwind of federal cuts: The Centers for Medicare & Medicaid Services would soon shutter Making Care Primary, a year into what was supposed to be a 10-year program. Nearly 700 practices in eight states enrolled in Making Care Primary. North Carolina had 23 clinics and centers in the program, the most of any state, followed by Washington, New Mexico, and New York. Doctors who had signed up for it said they were stunned.
“I’m angry, but more than that, I am so very sad,” Hall said. “It’s heartbreaking — to have an already inadequate health care system be made even more inadequate, to throw away opportunities to improve, even a little.”
Now, CMS’ Innovation Center, which created Making Care Primary, is set to launch a new 10-year program to boost primary care called the Long-term Enhanced ACO Design, known by its acronym LEAD. In that program, funding will be sent to health care organizations, often managed by companies, instead of directly to primary care doctors and clinics.
CMS wouldn’t say how much the programs cost. But it maintained that eliminating Making Care Primary reduced spending without sacrificing its mission to improve quality of care. Nixing Making Care Primary and three other programs at the agency — including another focused on primary care — would save taxpayers $750 million, CMS said at the time.
Making Care Primary “was not on track to meet its intended savings goal,” CMS spokesperson Alexx Pons said. Innovation Center models are meant to save money over time, in part by improving patients’ access to health care and helping them avoid costly hospital visits. Practices that signed up for Making Care Primary and want to join LEAD will have to apply for the program beginning in March.
Yet Making Care Primary’s elimination has created skepticism among doctors. The change exacerbated their fears about uncertain funding overseen by the Trump administration as COVID-era Medicaid provisions expired, enhanced Affordable Care Act subsidies ended, and Congress passed more funding cuts in President Donald Trump’s One Big Beautiful Bill Act.
William Hathaway, a physician and the CEO of the Mountain Area Health Education Center in western North Carolina, which serves 16 mostly rural counties, questions how his organization is supposed to plan for the future “when the future can just go away so quickly.”
A chance to change primary care
The U.S. is facing a primary care crisis. In 2023, more than 100 million people in the U.S. had no access to a primary care doctor in their area, the National Association of Community Health Centers reported. Some states, such as Colorado, have passed legislation to ensure more primary care funding at the state level.
The health care shortage where Hall works in western North Carolina is so severe, she said she often makes personal calls to doctors to schedule appointments.
Hall said one of her patients is an uninsured woman who has been waiting six months for a colonoscopy. The patient has severe anemia and possibly gastrointestinal bleeding. Hall has been trying to get the patient somewhere that offers free or discounted care.
The additional funding through Making Care Primary would have allowed the network of clinics to improve its communication systems with specialists. Coordination of this kind of care is one of the challenges Making Care Primary was supposed to address.
“I’m still not sure what we’re going to do for her,” Hall said.
Making Care Primary sought to create an efficient payment system for primary care clinics and help them better track patients, allowing doctors to be less burdened by administrative duties and focus more on care.
It provided bonuses to primary care doctors for maintaining their patients’ health, as well as flexible funding that could be used to improve patients’ quality of life in numerous ways. That included patients’ transportation to health care facilities, food vouchers, moving expenses, or help with utility bills.
Spokespeople for health departments in the states that signed up for Making Care Primary said some doctors have since lost trust in federal support.
“It can be difficult for providers, especially smaller community base practitioners, to pool resources to invest in non-clinical development,” said Cadence Acquaviva, a spokesperson for New York’s health agency. “An abrupt change can damage the confidence in future programs’ sustainability.”
An uncertain future
The CMS Innovation Center tests health care models to find those that improve care and lower costs for the health system and patients. The center created Making Care Primary after testing it as one of those models. It’s unclear whether the models have ultimately saved money; a 2023 Congressional Budget Office report criticized the Innovation Center for increasing spending by nearly double the amount the CBO projected the center would save in taxpayer money over 10 years.
Elizabeth Fowler, who directed the center under President Joe Biden, said Making Care Primary ended so early that it could not have produced any meaningful data on whether the patients it served became healthier.
Fewer clinics volunteered to participate in the program than expected, she said. But if the decision on whether to cut the program were hers to make, “I would have said, ‘It’s not enough time,’” Fowler said. “It takes more than a year to get the numbers.”
Hathaway said his Mountain Area Health Education Center signed on to Making Care Primary believing it could change the profession: It promised to ensure practices received immediate, consistent federal money to enhance primary care. Other models made that funding more difficult to obtain.
It’s unclear whether LEAD will draw more enrollment than Making Care Primary, but Hathaway, who has years of experience with elements included in LEAD, is skeptical of the program.
“Anytime you put multiple layers of bureaucracy between us and the patients and the dollars, it just costs more,” he said.
Hall said doctors “see the suffering firsthand” but often feel helpless in a system that cuts people off from primary care. She has been frustrated with the nation’s health care system, she said, which she feels focuses on profits over patients.
“We should be rolling out the red carpet for everybody to come see their family doctor and keep them out of the emergency room,” Hall said. “That would keep costs lower for the whole system. I’m wearing rose-colored glasses now, but I really believe that.”
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