For 25 years, the Graham Center has played a pivotal role in informing policy and primary care practice by producing high-quality evidence about the value, dimensions, and needs of primary care. In this article, past and current leaders of the Graham Center reflect on its history, impact, and future direction.

ORIGINS

Recognizing the need for objective, policy-relevant research capable of bringing a family medicine and primary care perspective to national policy deliberations, the American Academy of Family Physicians' leader Robert Graham and his Board of Directors launched a research center in Washington, D.C., in 1997. This enterprise was built on a novel founding principle among medical associations—editorial independence—positioning it to become a credible source of peer-reviewed publications and evidence that policy makers could trust. In the summer of 1999, Larry Green was hired as the founding director of the AAFP Center for Policy Studies in Family Practice and Primary Care, which was later renamed the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. Through queries of nearly 400 individuals (i.e., practicing family physicians, pediatricians, internists, representatives of national professional organizations, medical and nursing school deans, chairs of academic departments, residency directors, legislators, government agency leaders, advocacy organizations, philanthropies, and founders of family medicine and primary care), the initial areas of focus for the Robert Graham Center were formulated, including scope of practice for family physicians, investment in primary care infrastructures, and universal health coverage.¹

IMPACT

From its inception in 1999, the Graham Center has grown from five to 11 full-time staff. A geospatial team and qualitative staff were added to help contextualize and visualize the impactful analyses that have informed policy conversations. The staff are responsible for nearly 800 peer-reviewed publications and countless reports used by academic departments, policy makers, and government agencies to inform workforce and training decisions.² Its early collaboration with the National Association of Community Health Centers supported a doubling of health centers in the early 2000s.³ Early geospatial analytic research led to the creation of HealthLandscape and the Uniform Data System Mapper, which helped the Health Resources and Services Administration (HRSA), states, and health centers make more effective expansion decisions involving billions of dollars per year through use of patient and population data. The outcomes analyses for residency training helped HRSA launch the Teaching Health Center Program, aided states in making better investments in workforce production, and enabled Congress to understand if its intentions for residency redistribution were being honored.^4,5 The Graham Center has been an important leader in characterizing the errors that occur in primary care settings, and its role was critical in developing small-area deprivation indices that helped make the case for increasing funding to practices caring for the underserved.^6–10 The Graham Center is demonstrating the consequences of the loss of primary care workforce production that it identified more than a decade ago.^11–13 One of its earliest translations of public data for general good was the creation of the Medicare Graduate Medical Education funding tables, which residency programs use to understand the flow of funds to support training.¹⁴

Aside from these research products, the Graham Center's influence in primary care policy decisions has allowed it to become a convener of diverse and influential voices to debate and disseminate foundational work for the primary care community. The Primary Care Forum series brings together international researchers and policy makers to inform audiences about salient issues affecting primary care and generate discussion among attendees.¹⁵ The Graham Center's involvement in the first Starfield Summit in 2016, alongside the Pisacano Leadership Foundation, Family Medicine for America's Health, and the American Board of Family Medicine Foundation, set the stage for a series of summits that have generated changes in the definition of primary care, improved funding for graduate medical education, and increased access to care.¹⁶

ELEVATING PRIMARY CARE SCHOLARSHIP

The Graham Center has always valued collaboration and developing people with capacities to imagine, evaluate, and lead policy changes. It has constantly welcomed and fostered individuals at every career level from multiple specialties and disciplines. More than 400 scholars and fellows have worked with the Graham Center in the past 25 years. In the past 5 years, they have helped to produce more than 50 publications, research presentations, and posters covering topics from behavioral health integration in primary care to evaluation of alternative payment models. Fellows have collaborated with federal agencies, including the HRSA, Office of the Assistant Secretary for Health, and Agency for Healthcare Research and Quality. Many have gone on to work for these institutions and promote primary care research. The success of these individuals cannot be measured in publications and presentations alone. Early career scholars have taught research methods to their colleagues and promoted the scholar program to other junior researchers. Advanced researchers return to their home institutions with improved skill sets and the ability to promote research within academic and private organizations across the United States and Canada. Scholars and fellows have leadership positions in organizations across primary care, including the North American Primary Care Research Group, American Medical Association, and American Board of Family Medicine. This growing network continues to elicit new partnerships and opportunities.

WHERE WE ARE NOW AND WHERE WE ARE GOING

Many of the barriers to achieving health through robust primary care remain as powerful today as they were in 1999, perhaps even amplified by an increasingly specialized and fragmented health care delivery system. Early focus points of the Graham Center investigations such as scope of practice, sufficient investment in primary care infrastructure, and the achievement of universal health coverage continue to demand attention. However, as the factors impacting access to primary care have evolved, so have the Graham Center's priorities. The increasing presence of laws that restrict what physicians can do, and what conversations they can have with their patients, has motivated the Graham Center to turn its attention to family medicine's role in reproductive care and health equity. In 2024, investment in primary care infrastructure continues to be an issue, but programs and initiatives that were not present in 1999 have emerged. The result of these shifting initiatives is a more recent focus on the impact of primary care spending on access to care and whether states have improved their investment in primary care. Access to care has become more than a question of universal health coverage. Workforce availability and forces outside of health care, such as social determinants of health and structural racism, impact the ability of the U.S. population to receive high-quality health care. In response, the Graham Center has been compelled to study the influence of the physician-patient racial concordance on health, the impact of structural racism on creating a diverse physician workforce, how changing graduate medical education policies have transformed the geographic distribution of the workforce, and the increasing use of community resources to reduce the effects of social disadvantage on community health.¹⁷ As issues in health care continue to evolve, so will the research focus of the Graham Center. What will remain constant is the commitment to bringing a family medicine and primary care perspective forward to fuel movement toward better, affordable health care for all people in the context of their families and local communities.