Primary care in the United States and its precarious future.

Primary care has not secured a firm place within the US health services system. Since primary care lacks a strong research base, is not institutionalized in medical education or in policy-making and is marginalized in both proposed and actual reforms, it has not developed into a central component of the health care infrastructure. We discuss recent efforts that promised modest improvements, including the Clinton health care reform proposals and subsequent federal and state actions, in the role of primary care within the health services system. We also assess the likely fate of primary care given the accelerated growth of managed care and market competition, the dissatisfaction of large segments of the population with managed care and misperceptions of managed care as synonymous with primary care. We highlight how managed care fails to achieve the cardinal functions of primary care and summarize initiatives that, at a minimum, would be required to secure a stronger position for primary care in the future.