Everybody's Foundation, Nobody's Business

It is time for the big conference keynote, and the room is full. Cost pressure has sharpened, the healthcare system appears ready for another round of reinvention, and primary care is presented as the foundation of a better-functioning model. This is where trust develops, chronic conditions are managed, prevention becomes possible and unnecessary care can be avoided.

The keynote could be delivered this year. It could have been delivered in almost any year over the past two decades. There is truth in it. The debate is not whether primary care matters. It does. The harder question is what the businesses of healthcare expect primary care to do once they pay for it.

Even the spending numbers reveal how unsettled the category remains. The 2026 Primary Care Scorecard found that primary care’s share of total healthcare spending declined from 13% in 2022 to 12% in 2023 under a broad definition that includes nurse practitioners and physician associates across outpatient specialties, behavioral-health clinicians and obstetrician-gynecologists. Under a narrower definition limited to primary care physicians, spending fell from 4.6% to 4.5%. The measured share of spending changes materially depending on what the system decides belongs inside primary care.

In private, the agreement on what primary care needs to be breaks down quickly. We have had versions of this discussion with physicians and executives who sit close to primary care delivery, product design and market strategy. Each sees the problem, and the value argument, differently.

There is the employer that wants to place more capital and design intent around primary care. From that seat, giving physicians more time with employees, retaining more revenue inside the practice and reducing the pressure to feed downstream services can look like an obvious improvement. Yet when dominant local institutions own much of the physician supply, an independent relationship can appear less like a partner to the existing system than a new route through which patients, referrals and spending might leave it.

An insurer line-of-business leader once explored direct primary care as part of a product strategy. The trouble arrived during design, when internal teams struggled to identify where the membership practice’s defined services ended and an insurable claim began. The idea was clean. The surrounding machinery, built to recognize standardized covered services, networks, referrals and claims, was not. Within that design, there was no natural category for an ongoing clinical relationship that existed partly outside the transaction.

Then there are primary care physicians who traded the white coat for a business suit. They still value the time spent with patients, but they have also seen the machinery up close and no longer speak confidently about primary care saving the system. Some moved to the level where budgets and care models are set but not delivered, carrying an understanding of both the relationship and the forces that keep reshaping it.

The employer saw a market protecting existing relationships. The insurer encountered an architecture without a clean category for the service. The clinicians saw a professional model losing its promise. Each saw something real. None saw the same failure.

The public record is no cleaner. Walmart closed all 51 of its health centers and its virtual-care operation in 2024, citing a challenging reimbursement environment, escalating operating costs and the absence of a sustainable model for Walmart at that time. The qualification matters. Walmart did not leave health and wellness broadly; its current business still includes pharmacy, optical, hearing and other health services. It exited the owned primary care clinic model it had placed inside a large consumer enterprise.

VillageMD tested a different proposition: whether a pharmacy-led enterprise could rapidly assemble and scale a physician platform as part of a broader healthcare strategy. After approving approximately 160 clinic closures during the first nine months of fiscal 2024, VillageMD approved another 28 during the comparable 2025 period. Walgreens also recorded a further $3 billion in VillageMD-related goodwill and long-lived-asset impairments, while certain legacy Village Medical and Summit assets entered a sale process. Those impairments were not equivalent to clinic operating losses. They represented an accounting judgment that the estimated value of the strategy had fallen substantially. 

Oak Street Health tested a third model, built around capitated care for Medicare-eligible patients. Its 2023 investor materials showed “platform contribution,” a company-defined measure excluding depreciation and amortization, remaining negative through a center’s first two years, becoming positive around year three and reaching what Oak Street called mature performance in year six and beyond. That does not imply all primary care has a six- or seven-year maturation horizon. It does show that one sophisticated model expected its centers to mature over a period longer than the planning and reporting cycles through which many organizations are asked to demonstrate progress.

CVS initially projected that Oak Street would operate more than 300 centers by 2026, with substantial earnings and synergy potential. The subsequent record became more complicated. In 2025, CVS decided to reduce new primary care openings beginning in 2026 and to close certain existing Oak Street centers, revising the growth assumptions that had supported the acquisition. The company recorded a $5.7 billion goodwill impairment for its broader Health Care Delivery reporting unit, which included both Oak Street and Signify Health and therefore cannot be assigned entirely to Oak Street. At the end of 2025, CVS still operated 246 centers serving approximately 500,000 patients, and its first-quarter 2026 filing continued to identify Oak Street as a healthcare-delivery asset. It also warned that persistently elevated utilization could pressure those assets. CVS had not abandoned the model. It had changed the pace and economics surrounding it before the original growth thesis fully played out.

These were not three companies conducting the same primary care experiment or reaching the same verdict. Walmart exited its clinic model. Walgreens entered a prolonged strategic retreat. CVS recalibrated an asset it continues to operate. Each enterprise had assigned primary care a different job and reached a different threshold for continuing to fund it.

The more revealing question is no longer simply whether the clinic works. It is what else must work around the clinic, and on what timeline, before the enterprise considers the relationship valuable.

The economic home changes the job.

A health system can provide capital, specialist access, shared clinical records, operating infrastructure and a durable local presence. In some communities, it may be the institution most capable of keeping a practice open and coordinating complex care. Primary care also becomes the front door to the rest of the enterprise.

A study of commercially insured patients in Massachusetts found that relationships between primary care physicians and large health systems were associated with more specialist visits, more care delivered inside the affiliated system and higher total medical spending. The findings did not establish motive, nor did they prove that the additional care was inappropriate. Greater integration could improve access, coordination and the exchange of information. The study did show that ownership can change where care flows and where its economic value is captured. For a system leader, the difficult question is where coordination ends and captive flow begins, and who recognizes the difference when both improve the same income statement. 

A payer may be best positioned to see value outside the office visit because it can see claims, population risk, care gaps and downstream utilization. Under a sufficiently durable risk arrangement, it can finance work that encounter-based reimbursement may never recognize. Its limitation is tenure. A member can change products, employers or carriers before the investment matures, leaving the organization that funded the relationship without the eventual economic return.

An insurer-owned primary care platform may also be expected to improve attribution, risk performance, utilization, coding accuracy, product differentiation and retention. The operating question becomes harder when those objectives stop pointing in the same direction. Which objective governs when the best clinical decision does not improve the product, the risk score or the near-term medical-cost result?

The Blues may have the local density and institutional duration to wait, while carrying many of the same product, network and margin pressures that shorten the horizon.

An employer enters from another direction. It can focus on access, employee trust, productivity and total benefit cost without first protecting an existing delivery network. It can choose the design, financing and partners, but it controls relatively little of the delivery system surrounding the clinic. Employees leave, budgets reset, and the employer does not control hospitals, specialists, local prices or physician supply.

Primary care can therefore become both workforce infrastructure and a workaround for failures elsewhere in the benefit. That may still be valuable. The question is whether the employer can sustain the investment long enough, and whether a model operating beside the health plan can influence the expensive care that occurs outside the clinic.

A physician-led or membership practice may preserve the clearest alignment between clinician and patient. A smaller panel can create more time, improve access and reduce the administrative demands placed on the relationship. It also has less capacity to absorb early losses, build infrastructure, coordinate the expensive parts of the delivery system or serve people who cannot pay outside their existing coverage. Smaller panels may deepen the relationship for those inside them while tightening access for those left outside.

Capital-backed operators can finance early losses, recruit clinicians, build technology and operating infrastructure, and create alternatives that incumbent institutions may have little incentive to develop. Without outside capital, many new care models would never leave the whiteboard. The capital also requires growth, an economic return and, eventually, liquidity. These are the conditions attached to the money.

The June 2026 settlement between California and Carbon Health places a sharper boundary around that arrangement. The state alleged that Carbon Health’s management-services structure gave a nonmedical entity effective control over physician-owned practices, including the power to replace physician-owners. The proposed settlement, which remains subject to court approval, would require restructuring and impose $4.5 million in combined penalties. It does not prohibit outside investment or the broader management-company model. It raises a narrower and more consequential question: How much operating control can the capital provider require before it also controls the practice of medicine? 

Primary care is not nobody’s business. It is repeatedly made part of somebody else’s business.

Every economic home can make a legitimate case for why the relationship belongs inside it. The more consequential question is whether the adjacent economics sustain primary care or eventually govern it. The relationship is the feature every owner claims to value most, and the feature each must reshape to fit the enterprise around it.

The strongest objection is that ownership is not the underlying problem. It may only be where inadequate payment, workforce constraints, fragmented coverage and patient mobility become visible. A different owner cannot create clinicians who do not exist, keep patients from changing jobs or plans, or capture savings that appear on another organization’s ledger.

The latest evidence is mixed rather than uniformly bleak. In 2023, the number of primary care physicians remained stable at 67 per 100,000 people, while the broader supply of primary care clinicians increased after a prior decline. The proportion of new physicians entering primary care rose from 18.6% to 22%. At the same time, 29.7% of adults reported having no usual source of care. Small improvements in workforce supply and continued weakness in access can coexist. 

Changing the owner without changing how primary care is paid, staffed and retained may only move where the contradiction appears. Changing payment without asking who controls the relationship may finance a better-capitalized version of the same distortion. Ownership, payment and continuity are not competing explanations so much as interacting constraints. Each one changes what the others can accomplish.

Before an organization builds, buys or sponsors primary care, a few questions are worth more than another pro forma. What are we asking the relationship to produce, and on whose income statement must that value appear? How long will we retain the patient, member or employee relative to the time the model needs to mature? Which adjacent business must improve for the clinic to remain funded? What happens if the patient benefits but the surrounding enterprise does not? When clinical judgment and enterprise economics diverge, who decides?

The keynote will run again next year. Primary care will still be foundational, and the room will still nod along. The market has shown that plenty of capable organizations can buy, build or sponsor it. What it has not settled, and what remains harder to ask from a stage, is who among them can afford to let primary care remain primary care.