UCSF family physician Dr. Kevin Grumbach is floating a sweeping yet deceptively simple idea for California: treat primary care like a public utility. His blueprint would pool existing dollars from health plans and other payers into a single common fund that pays primary care clinicians directly, so every Californian could see a primary care doctor regardless of what insurance card they carry.
The concept is meant to cut through today’s billing tangle, push more money into front-line clinics, and break the tight link between a person’s insurance plan and where they can get basic care. Supporters frame it as a practical first step toward broader universal coverage. Skeptics warn that the political fights and federal legal hurdles between here and reality are anything but small.
What the JAMA authors propose
In a Viewpoint published last Wednesday in JAMA, Grumbach and co-authors outline how a "primary care common fund" could work. Payments from insurers, employers, and government purchasers would be pooled, then paid straight to primary care practices instead of bouncing through dozens of separate contracts.
The authors argue that state efforts to invest in primary care are often constrained by fragmented coverage, leaving large swaths of residents outside direct state control. A single fund, they write, could channel money into primary care without tearing down the rest of the insurance system. The paper also sketches governance options, suggesting the fund could sit under a public or quasi-public entity and could back alternative payment models that support team-based care.
How it would work in California
Grumbach and his colleagues say California is an ideal test bed because the state already has policies nudging more dollars toward primary care. As reported by the San Francisco Chronicle, the proposal would keep people’s existing insurance in place while making primary care effectively universal by diverting a share of payer dollars into the common fund. "We are calling for, essentially, single-payer for primary care," Grumbach told the paper, pitching the common fund as a concrete and politically realistic starting point on the way to more unified health care financing.
State targets and the math
California’s Office of Health Care Affordability has already planted a flag. It set a benchmark to raise primary care spending to 15 percent of total medical expenses by performance year 2034, a target detailed in its investment benchmark memo. The Office of Health Care Affordability calls for steady year-over-year gains starting in 2025, so the statewide share climbs gradually toward that goal.
At the same time, the price tag for full universal coverage remains hefty. A 2019 UC Berkeley white paper pegged the annual cost of statewide universal coverage at an estimated 17.3 billion dollars, a reminder of why targeted experiments in primary care financing may be a more politically manageable opening move, per UC Berkeley.
The federal and legal hurdles
Turning the common fund from an academic proposal into a state law would mean wrestling with Washington. Redirecting Medicare, Medi-Cal, and self-insured employer dollars would almost certainly require permission from federal agencies.
Experts quoted by the San Francisco Chronicle, including KFF’s Larry Levitt, say that kind of shift would likely hinge on federal waivers and intense negotiations over what money can be bundled and how. California lawmakers have already taken an early step by passing SB 770 in 2023, which directs state agencies to craft a waiver framework and report back to the Legislature with a timeline.
Politics and next steps
Designers of the proposal say the common fund is meant to be modular. It could start small, with pilots or specific populations, and then expand if it proves workable. The JAMA article argues it could be done without altering the insurance, payment, and delivery of health care outside of primary care, which is a selling point for wary lawmakers and health plans.
The authors stress that making the fund real would require careful work on how to measure performance, who governs the money, and how equity is built in from the start. Pilot programs, they add, will be needed to show whether pouring more resources into primary care actually improves access on the ground. Whether that planning and political heavy lifting happens will depend on governors, legislators, and health plans deciding to back concrete pilots and pursue the waivers they would need.
What it could mean for patients
For patients, the promise is straightforward: faster access to primary care visits and fewer back-and-forth trips to the front desk. Clinics would bill a single fund instead of juggling dozens of contracts, which proponents say could free up staff time for actual care.
More predictable payments to primary care practices could also help support team-based care, same-day appointments, and outreach in neighborhoods that have been shortchanged on basic services. Those are exactly the kinds of changes the state’s primary care investment benchmark links to better equity and outcomes. The Office of Health Care Affordability says it plans to publish payer-level progress toward the benchmark, which would give the public a way to see whether money is truly shifting toward community clinics and front-line care.
