NYHealth President and CEO David Sandman testified at the New York State Joint Legislative Budget Hearing: Health/Medicaid on January 23, 2024. In his testimony, he addressed the opportunity for New York to improve health outcomes and save money by investing in primary care and expanding the role of Medical Assistants on primary care teams.
(The recording of Dr. Sandman’s oral testimony at the hearing is available here.)
Thank you to Chair Krueger, Chair Weinstein, and members of the Senate Finance and Assembly Ways and Means Committees for the opportunity to testify today. I am pleased to provide testimony on behalf of the New York Health Foundation (NYHealth), a private, independent, statewide foundation dedicated to improving the health of all New Yorkers, especially people of color and others who have been historically marginalized.
As we aim to transform New York’s health care system—improving the accessibility, quality, and equity of care while controlling costs—a top priority must be expanding and strengthening primary care. To further advance this work, New York should:
- Devote a greater share of its total health spending to primary and preventive care and
- Empower members of primary care teams, including Medical Assistants, to take on more responsibilities and relieve strain on providers.
The Proven Benefits of Primary Care
Primary care is often a patient’s first point of contact in the health care system. Evidence has repeatedly proven the benefits of accessible, high-quality primary care. People who receive primary care are significantly more likely to get preventive care like cancer screenings, flu shots, and nutrition counseling.[1] They also experience better health outcomes and management of chronic diseases like diabetes and asthma.[2] And primary care is a rare “win-win” for health care: it is associated with both better health and lower costs. Better access to primary care means fewer hospital visits, fewer emergency department visits, and fewer surgeries—which means reduced health care costs.[3]
Expanding access to primary care is inextricably linked to enhancing racial health equity, as shortage areas in New York State are often communities of color where patients face barriers to getting care when and where they need it. One in three New Yorkers lives in an area with inadequate primary care access.[4] The gaps are greatest in communities of color and rural communities across New York State; for instance, the odds of being in an area with poor access to primary care providers were 28 times greater in Census tracts with a high Black population than in areas with a low Black population.[5]
The Case for Smarter Investment in Primary Care
Despite the mountain of evidence showing its value, we continually underinvest in primary care. Primary care accounts for only an estimated 5–7% of all health care spending.[6],[7] In simple terms, we only spend about a nickel of every health dollar on primary care. Not only is primary care spending lower in New York than the rest of the country, but it has also decreased over five years.[8]
While we underspend on primary care, we do spend vast sums on health care overall in New York—20% higher than the national average by some analyses.[9] But that spending isn’t providing enough value for New Yorkers; our health outcomes are average and often poor in comparison with other states.[10]
We can do better. The solution is to rebalance health care spending by allocating a greater percentage of what we spend to primary care. Doing so doesn’t require spending more on health care; it requires spending in smarter and better ways that return more value for our dollars. Rebalancing primary care spending is a vehicle for expanding access to preventive care, ensuring more entry points into the health care system, and promoting more cost-effective and equitable care.
New York State should set a specific and ambitious target for increasing overall investment in primary care as a share of total health care spending. In doing so, we’d be catching up to much of the nation. At least 19 other states have adopted policy changes that address investments in primary care.[11] States that have been early adopters of policies requiring an increased proportion of health care spending on primary care have seen that work translate to decreases in overall health care costs and increases in the primary care workforce. A prime example is Rhode Island, which set targets to increase the share of commercial insurer primary care expenditures by 5% over a 5-year period. Over that same period, the State’s total health care expenditures fell by 14%, and there was an increase in primary care providers per capita.[12]
New York should not lag these other states. The Legislature has recognized the importance of this issue and attempted to address it. Both houses previously passed bills to establish a primary care reform study commission, but they were vetoed by the Governor, who asserted that we already knew we underspend on primary care. In this session, Senator Rivera and Assemblymember Paulin have introduced bills (S01197/ A08592) to require health care plans and payors to gradually have a minimum of twelve and one-half percent of their total expenditures on physical and mental health annually be for primary care services.
Enhancing the Critical Role of Medical Assistants on Primary Care Teams
Investing in primary care is the fundamental—but not the only—way to enhance patients’ ability to access primary care and improve providers’ ability to deliver care. New York can also take steps now to combat workforce shortages and strains across the health system. One solution is to elevate the role of Medical Assistants (MAs).
An MA is a critical member of a primary care team who performs administrative and certain clinical duties under the direction of a physician or another supervising clinician.[13] MAs are often members of the communities they serve, including communities of color, so they are uniquely positioned to build relationships with patients and earn their trust.[14] The profession offers a pathway to equitable career advancement and is expected to grow in New York by 27% between 2020 and 2030, much faster than other health care occupations.[15] MAs are capable of—but currently underutilized in—supporting high-quality patient care.
New York has lagged other states in making the most of MAs’ potential. This was cast into relief during the COVID-19 pandemic, when New York’s health system was strained by the massive task of immunizing New Yorkers. New York did not allow MAs to administer COVID vaccines, in contrast to neighboring states like New Jersey and Connecticut, along with many others.[16],[17],[18] New Jersey and Connecticut have since made these temporary COVID provisions permanent; administering vaccinations is now an officially permissible task of MAs. More than 40 states allow MAs to perform clinical tasks, such as administering vaccinations, under the supervision of a clinician.[19],[20] The benefits are manifold: care teams that use MAs beyond administrative and basic clinical duties often see improvements in patients’ use of health services and health outcomes;[21],[22] improved clinical quality metrics and operational efficiencies;[23],[24] and reductions in provider strain and burnout.[25]
The proposed Executive budget aims to bring New York on par with other states; carefully and narrowly crafted provisions will enable MAs with appropriate training to administer vaccinations under the supervision of physicians, physician assistants, and nurse practitioners. Permitting MAs to administer vaccinations will increase the number of health care professionals that are able to do the critical work of protecting New Yorkers against severe disease. It would free up clinicians to use their time and clinical expertise to meet more complex patient care needs.
There is no silver bullet to solve New York’s workforce shortage. But an immediate and common-sense piece of the solution is to immediately enhance the role of MAs and to allow other clinicians to practice at the top of their licenses.
Conclusion
Primary care is the backbone of a high-functioning health care system. Greater investment in primary care as a percentage of total health spending will lead to a healthier New York and a more cost-effective system. Supporting and strengthening the primary care workforce will position New York as a national leader. Together these efforts will advance racial health equity.
NYHealth has long supported efforts to advance primary care; we have a concerted focus on expanding access to primary care, advancing racial health equity through primary care, and strengthening the primary care workforce across New York State. We stand ready to work with you on these shared goals.
[1] Levine DM, Landon BE, Linder JA. “Quality and Experience of Outpatient Care in the United States for Adults With or Without Primary Care,” JAMA Internal Medicine 2019;179(3):363–372. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2721037.
[2] Shi L, “The Impact of Primary Care: A Focused Review,” Scientifica. 2012; 2012:432892. https://www.hindawi.com/journals/scientifica/2012/432892/.
[3] Kravet SJ, Shore AD, Miller R, Green GB, Kolodner K, Wright SM. “Health Care Utilization and the Proportion of Primary Care Physicians,” The American Journal of Medicine, 2008 Feb;121(2):142-8. https://www.amjmed.com/article/S0002-9343(07)01088-1/fulltext.
[4] Kaiser Family Foundation, “Primary Care Health Professional Shortage Areas (HPSAs)”, https://www.kff.org/other/state-indicator/primary-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&selectedRows=%7B%22states%22:%7B%22new-york%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D, accessed January 2024.
[5] Brown E, Polsky D, Barbu C, Seymour J, Grande D. “Racial Disparities in Geographic Access to Primary Care in Philadelphia,” Health Affairs 2016; 35(8). https://www.healthaffairs.org/doi/10.1377/hlthaff.2015.1612.
[6] Patient-Centered Primary Care Collaborative, “Investing in Primary Care: A State-Level Analysis,” July 2019.
https://www.pcpcc.org/sites/default/files/resources/pcmh_evidence_report_2019_0.pdf.
[7] National Academies of Sciences, Engineering, and Medicine, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care, Washington, DC: The National Academies Press, May 2021. https://www.nationalacademies.org/our-work/implementing-high-quality-primary-care#sectionPublications.
[8] Milbank Memorial Fund, “The Health of US Primary Care Baseline Scorecard Data Dashboard,” February 2023. https://www.milbank.org/primary-care-scorecard/, accessed January 2024.
[9] New York Health Foundation, “Health Care Spending Trends in New York State,” October 2017, https://nyhealthfoundation.org/resource/health-care-spending-trends-in-new-york-state/. Accessed February 2023.
[10] America’s Health Rankings analysis of America’s Health Rankings composite measure, United Health Foundation, State Findings: New York, 2021. https://www.americashealthrankings.org/explore/annual/state/NY.
[11] Primary Care Development Corporation, “Primary Care Legislative Trends 2023,” January 2024, https://www.pcdc.org/wp-content/uploads/2023-State-Primary-Care-Legislation-Trends-FINAL_010423.pdf, accessed January 2024.
[12] Koller C. & Khullar D. Primary Care Spending Rate – A Lever for Encouraging Investment in Primary Care. New Eng. J. Med. 2017. 377(18) 1709-1711. Doi:10.1056/NEJMp1709538.
[13] U.S. Bureau of Labor Statistics, “Occupational Employment and Wages, May 2022: 31-9092 Medical Assistants,” https://www.bls.gov/oes/current/oes319092.htm, accessed March 2023.
[14] U.S. Census Bureau, “ACS 1-Year Estimates Public Use Microdata Sample,” Racial demographics available at https://data.census.gov/mdat/#/search?ds=ACSPUMS1Y2021&cv=RAC1P&rv=ucgid,OCCP%283645%29&wt=PWGTP&g=0400000US36. Ethnicity demographics available at https://data.census.gov/mdat/#/search?ds=ACSPUMS1Y2021&rv=HISP,ucgid,OCCP%283645%29&wt=PWGTP&g=0400000US36, accessed June 2023.
[15] New York State Department of Labor, “Long-term Occupational Projections,” https://dol.ny.gov/long-term-occupational-projections, accessed June 2023.
[16] Declaring a Disaster Emergency in the State of New York. NY Exec Order No. 202. (March 2020). https://www.governor.ny.gov/sites/default/files/atoms/files/EO_202.pdf.
[17] Authorization for Members of the Healthcare Provider Community to Conduct COVID-19 Vaccination Administration. NJ Exec Directive No. 20-037. (March 2020). https://www.state.nj.us/health/legal/covid19/ExecutiveDirectiveNo20-037_HCPVaccinationAuthorization.pdf.
[18] An Act Allowing Medical Assistants to Administer Vaccinations. CT Senate Bill No. 213. (March 2022). https://www.cga.ct.gov/2022/fc/pdf/2022SB-00213-R000217-FC.pdf.
[19] American Medical Association, “Medical Assistants’ Scope of Practice,” 2015, https://legislature.vermont.gov/Documents/2018/WorkGroups/House%20Government%20Operations/Bills/H.496/Witness%20Testimony/H.496~Jessa%20Barnard~AMA%20Chart~1-10-2018.pdf, accessed January 2024.
[20] American Association of Medical Assistants, “State Scope of Practice Laws,” https://www.aama-ntl.org/employers/state-scope-of-practice-laws#NJscope, accessed January 2024.
[21] Willard-Grace R, Chen EH, Hessler D, DeVore, Prado C, Bodenheimer T, Thom DH. (2015). Health Coaching by Medical Assistants to Improve Control of Diabetes, Hypertension, and Hyperlipidemia in Low-Income Patients: A Randomized Controlled Trial. The Annals of Family Medicine, 13 (2).
[22] Rodriguez HP, Friedberg MW, Vargas-Bustamante A, Chen X, Martinez AE, Roby DH. The impact of integrating medical assistants and community health workers on diabetes care management in community health centers. BMC Health Services Research. 2018, 18(875).
[23] Shaw JG, Winget M, Brown-Johnson C, Seay-Morrison T, Garvet DW, Levine M, Safaeinili N, Mahoney MR. Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support. Annals of Family Medicine. 2021, 19(5):411-418.
[24] Wagner EH, Flinter M, Hsu C, Cromp DA, Austin BT, Etz R, Crabtree BF, Ladden MJD. Effective team-based primary care: observations from innovative practices. BMC Family Practice 2017, 18(13).
[25] Sinsky CA, Willard Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices,” Annals of Family Medicine 2013; 11(3):272—278. 10.1370/afm.1531.
