Wendy Epstein

Primary care has long been described as the cornerstone of a functioning health system. Yet, in the United States, it is a cornerstone under strain. Patients who seek appointments with primary care physicians (PCPs) often wait weeks or months before they can be seen. Faced with these delays, many turn to urgent care centers, retail clinics, direct-to-consumer telemedicine platforms, or even at-home testing kits. While these alternatives offer quick access, they come at a price: fragmented care that sacrifices continuity, coordination, and comprehensiveness.

Sharona Hoffman and Ishani Ganguli’s article, Access to Primary Care and Health Care Fragmentation, argues that long wait times and the resulting fragmentation are not only health policy problems but also legal problems. They make the case that the combination of shortages and fragmentation undermines equity, drives up costs, and creates liability exposure under both tort and anti-discrimination law. Their insightful dual framing is compelling: primary care access failures threaten patient outcomes, but they also expose providers and health systems to lawsuits and regulatory scrutiny.

Traditionally, delayed or missed diagnosis claims arise where a patient has an ongoing relationship with a physician who fails to detect or follow up on concerning symptoms. But Hoffman and Ganguli argue that excessive wait times and fragmented care might create liability risks even when no such continuous relationship exists. A patient bounced among urgent care, retail clinics, and telemedicine providers may never have a single physician responsible for their longitudinal care. In those cases, fragmentation complicates questions of duty and causation — who, if anyone, is accountable when no one provider “owns” the patient’s trajectory? The authors suggest that under the right set of facts, these structural access barriers could create legal exposure.

They also identify anti-discrimination law as a potential source of liability. Long wait times do not burden all patients equally. Low-income individuals, racial and ethnic minorities, and those in rural areas are disproportionately affected, since they often have fewer PCPs in their communities and less flexibility to seek out alternatives. Hoffman and Ganguli suggest that if health systems or insurers are aware that their appointment practices disproportionately disadvantage vulnerable populations, yet do nothing to address the problem, that indifference could expose them to liability under federal civil rights statutes. Here, their analysis dovetails with broader debates in health law about structural discrimination and disparate impact. It also raises provocative questions about whether equity can be achieved in a system that places timely primary care out of reach for many of those who need it most.

Beyond liability, the authors also note that fragmentation in primary care is a hidden cost driver. Policymakers often assume that urgent care or telemedicine saves money by diverting patients from emergency departments. On the contrary, the article shows that fragmented encounters frequently duplicate tests, generate overlapping prescriptions, and increase downstream costs when preventive opportunities are missed. The economic argument reinforces the doctrinal one: when health systems push patients into disjointed care pathways, they not only compromise safety and quality but also waste resources and erode trust. This framing challenges conventional wisdom about “convenience care” and highlights how systemic incentives, left unchecked, may undermine the very efficiency they purport to achieve.

But running throughout the article is also an insistence that equity must remain at the forefront. The burden of long wait times falls hardest on those with the least access to resources, amplifying disparities that already exist in American health care. Fragmentation is not neutral: it disproportionately affects patients who already struggle to navigate the system, resulting in disjointed, duplicative, and ultimately less effective care. By centering these inequities, Hoffman and Ganguli remind us that primary care shortages are not only a cost and liability issue, but also a justice issue.

Hoffman and Ganguli thoughtfully explore solutions. They suggest that value-based payment models can give PCPs the resources and incentives to shorten appointment wait times and reduce fragmentation, for example by supporting the use of artificial intelligence to ease documentation burdens or by encouraging more effective scheduling strategies. They also examine state laws that directly regulate appointment wait times, critiquing their limitations and recommending clearer standards, potentially through federal legislation. Finally, they address structural capacity issues — including the limited number of primary care residencies and the financial and professional disincentives that make the field less attractive — and propose reforms to build the workforce over time. While the article acknowledges that no single intervention will suffice, it calls for a multi-pronged approach in which legal and regulatory levers play a central role.

Access to Primary Care and Health Care Fragmentation makes a valuable contribution by drawing connections between primary care shortages, liability exposure, systemic costs, and policy reform. The crisis of primary care is often framed as a problem of supply and efficiency, but Hoffman and Ganguli show it to be equally about liability, the true financial costs of fragmented care, and, most importantly, justice. For health law scholars, the piece highlights emerging doctrinal questions about malpractice and discrimination in fragmented care environments. For policymakers, it offers a roadmap for using law to rebuild primary care as the true foundation of U.S. health care.

Hoffman and Ganguli thus deliver both a warning and a vision. The warning: that without reform, primary care shortages will deepen inequities, raise costs, and undermine trust in the health system. The vision: that law can be harnessed to realign incentives, protect vulnerable patients, and restore primary care to its rightful place at the heart of American health care.