I recently met Diane Lund-Muzikant, publisher, editor, organizer and all ’round charm for The Lund Report.

Every state should have such a publication focused on the local health system. And a fireplug to match Diane’s energy. She said I could write an editorial whenever I would like to highlight primary care issues.

Here is my first effort published September 22, 2015.

The greatest success of Obamacare, is the reduction in the number of uninsured. Most of this improvement has come in lower income groups, who disproportionately suffer the burden of illness and the most difficult social circumstances, including poor employment prospects. So it is unsurprising that Medicaid expansion accounts for over 2/3 of the newly insured, according to the Heritage Foundation. The political partisans use this as a weapon arguing that Obamacare resulted in little more than the expansion of the Medicaid entitlement. The other side feels that more has to be done to cover the remaining 10 million uninsured.

What about the social value of medical coverage to vulnerable populations, the economic benefits of health care to this group and a questioning of the cost relative to the benefits? Sometimes it is OK to spend tax money if there is value and accountability. If our nation is to spend public money on healthcare, it is incumbent on policy-makers to ensure the greatest value for the effort.

The greatest public value derived from modern medicine is derived from immunizations, maternal-child health and primary care. When the newly insured report that they do not have access, they mean primary care docs who understand their situation and listen to their concerns. Unfortunately, the healthcare system as it stands commoditizes primary care and works against the functions of primary care, especially continuity. Each time someone looks for new primary care provider, the system has failed.

Because healthcare in the US is purchased through employers, their entire family would change provider when jobs turn over. As health plans move to narrow networks, odds are increasing that their doctor will not be in the network offered by the next employer. This interferes with continuity of care over time and erodes outcomes.

The situation is worse for low income individuals and the Medicaid population. Some in this population suffer from mental health problems and are easily overwhelmed by the normal demands of life. They find it difficult to hold onto jobs for a long periods of time. Unstable insurance source from a Medicaid provider to a narrow network and back, repeatedly forcing them into new primary care relationships.

Long term relationships between doctors and their patients build trust. It is the trust built on years of knowing the person embedded within the context of family and community which improves outcomes and reduces costs. The lower the income level, the greater the vulnerability, the greater the risk of bouncing on and off Medicaid, with lapses and fluctuating access determined by deductibles and coinsurance.

Erika Bliss, the CEO of QLiance, a Direct Primary Care company in Seattle, suggested to me a few months ago an idea that could help bolster how primary care improves health system performance. Perhaps it is time to consider a primary care benefit that is portable from employer to employer and continuous with Medicaid. It is easy to carve primary care out of traditional insurance, where it should always represent the top dollar of healthcare spending. This is the idea behind the growing Direct Primary Care movement where high impact primary care is paid for on a monthly subscription basis. First, this helps maintain continuity between a doctor and their patient, a foundation stone of primary care. Second, it serves to create a sustainable business model for medical students to do what they idealistically entered medicine to accomplish and attract more smart people to primary care specialties. Third, primary care increases the efficiency of healthcare systems around the world, which seems to be the fundamental motivation behind the notion of value-based purchasing. If you want to buy value, invest in primary care not MRIs and pay as much as you reasonably can.