From Harvard Findings to Island Action: Hawaiʻi’s Blueprint for U.S. Primary Care
- Esther Yu Smith
- Jan 7
- 2 min read
As a primary care doctor, I sometimes feel a reflexive weariness when yet another study is published concluding that we should spend more on primary care. Study after study has made the same point for decades: strong primary care improves health outcomes, advances equity, and lowers overall health care costs. The evidence is clear. What has been missing is not proof, but a practical way to turn that evidence into durable change.
What makes the 2025 Primary Care Investment Guide, developed by researchers at Harvard Medical School, different is that it moves beyond restating the problem. It focuses instead on how primary care investment must be structured if it is actually going to work.
The Harvard study compiles years of evidence showing that health systems that invest meaningfully in primary care experience fewer emergency department visits, fewer hospitalizations, and better chronic disease management, particularly in underserved communities. At the same time, it identifies a persistent failure: even when investment increases, the money often does not reach frontline primary care practices. Funds are absorbed by administrative overhead, diluted through complex incentive programs, or retained by payers and systems rather than supporting clinicians delivering care.
This gap between research and reality is especially stark in Hawaiʻi. The state faces a shortage of more than 150 full-time-equivalent primary care providers, with the greatest impact on neighbor islands and rural communities. Many residents have insurance but still cannot find a primary care physician. When local access erodes, patients delay care, rely on emergency departments, or travel between islands for basic services, worsening outcomes and increasing costs.
The Primary Care Protection Act is designed to close this gap by translating the Harvard study’s recommendations into enforceable policy.
First, the Act establishes a clear primary care investment floor by requiring health carriers to devote at least twelve percent of total medical expenditures to primary care. This aligns Hawaiʻi with national best practices and ensures that primary care funding is structural rather than discretionary.
Second, the Act ensures that investment reaches frontline clinicians. The Harvard study emphasizes that primary care funding only succeeds when dollars flow directly to care teams. The PCPA requires direct payment to primary care clinicians and prohibits diversion through administrative scoring systems or intermediaries.
Third, the Act stabilizes rural and neighbor island practices by protecting fair payment and timely reimbursement. Prompt-pay standards and limits on inappropriate downcoding provide predictable cash flow, which is essential for small and rural clinics.
Fourth, the Act strengthens access in underserved areas by recognizing same-day and walk-in primary care visits and protecting community access clinics from discriminatory reimbursement or contracting practices. These provisions reflect the realities of care delivery in rural Hawaiʻi.
Finally, the Act aligns Medicaid policy with workforce stability goals, ensuring that Med-QUEST payment rules support, rather than undermine, primary care access across all islands.
The Harvard study provides the evidence and the roadmap. The Primary Care Protection Act provides the mechanism to act. By directing existing health care dollars to frontline primary care and protecting access where it is most fragile, the PCPA offers Hawaiʻi a practical, evidence-based path toward better health outcomes, greater equity, and a sustainable primary care workforce.
Harvard Medical School Primary Care Investment Guide (2025):
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