Financial fitness for physicians

Is there a quiet revolution in primary care? For years, physicians practicing outside traditional fee-for-service models have lived in the gray space between innovation and policy inertia. Direct primary care (DPC) and telemedicine practices have grown rapidly—often despite regulatory friction rather than because of clarity.

On Jan 1, 2026, some of that friction quietly eased. The One Big Beautiful Bill Act (OBBBA) made headlines for many reasons, but its implications for cash pay primary care largely passed under the radar. By permanently allowing high deductible health plans (HDHPs) to cover telehealth and qualifying DPC services as compatible with health savings accounts (HSAs), OBBBA removed one of the most persistent structural barriers to relationship-based primary care.

The old problem

Before OBBBA, the rules were confusing. The IRS tended to qualify DPC practices, which charge a set monthly fee for primary care services, as a type of health insurance. That disqualified patients with DPC memberships from contributing to tax-advantaged HSAs, which require patients to be covered only by a qualified HDHP. 

Enter: Bronze plans

Much of the early conversation around DPC focused on employer-sponsored HDHPs. But OBBBA’s impact is arguably greatest in the ACA Marketplace, where Bronze plans dominate enrollment.

Bronze plans typically offer lower monthly premiums, higher deductibles and catastrophic coverage. Historically, they were dismissed as “catastrophic-only” and did not qualify for HSA Compatibility. After the OBBBA, Bronze plans are now fully compatible with HSA-qualified HDHP rules. In practical terms, this primary care model separates access from insurance risk in a way that is intuitive for both patients and physicians.

A patient enrolled in an HSA-eligible Bronze plan uses their insurance the way it was intended: for catastrophic protection and preventive screening. Hospitalizations, advanced imaging, specialty care and procedures remain within the insurance framework, subject to deductibles and out-of-pocket maximums. Day-to-day care, however, lives elsewhere.

That same patient enrolls in a DPC practice and pays a predictable monthly membership fee. Under OBBBA, that fee—within statutory limits—can be paid using HSA funds. 

How the costs compare 

For a typical adult patient in their forties, a traditional PPO often comes with higher monthly premiums. Additionally, patients pay per-visit copays, incur charges for telehealth encounters and still face deductibles for many services. 

By contrast, a patient pairing DPC with an HSA-eligible Bronze plan pays a lower insurance premium and replaces visit-based primary care costs with a flat monthly DPC fee. Over the course of a year, this combination often results in lower total predictable spending. 

Important clarifications 

While OBBBA simplifies access and financing, it does not eliminate the need for careful explanation. Physicians must remain clear about how this model functions alongside insurance. DPC fees do not apply toward insurance deductibles. It’s not a replacement for health insurance, and it is not designed to cover high-cost services. Laboratory testing, imaging, prescription medications, specialty care and hospital services continue to flow through traditional insurance channels and remain subject to deductibles. 

A rare alignment

Cash-based primary care no longer has to exist outside the system in order to function well. That shift is worth paying attention to. •