Primary care in the United States and its precarious future

Primary care has not secured a firm place within the US health services sys tem. Since primary care lacks a strong research base, is not institutionali zed in medical education or in policy-making and is marginalized in both pr oposed and actual reforms, it has not developed into a central component of the health care infrastructure. We discuss recent efforts that promised mo dest improvements, including the Clinton health care reform proposals and s ubsequent federal and state actions, in the role of primary care within the health services system. We also assess the likely fate of primary care giv en the accelerated growth of managed care and market competition, the dissa tisfaction of large segments of the population with managed care and misper ceptions of managed care as synonymous with primary care. We highlight how managed care fails to achieve the cardinal functions of primary care and su mmarize initiatives that, at a minimum, would be required to secure a stron ger position for primary care in the future.