By Hemant Kalia, MD, MPH, FIPP
This article was published in the RBJ https://rbj.net/2025/08/01/a-gilded-cage-for-primary-care-the-dangerous-promise-of-new-health-care-law/
For years, physicians pioneering the Direct Primary Care (DPC) model have fought for a simple change: to allow patients to pay for their affordable, membership-based primary care using their tax-advantaged Health Savings Accounts (HSAs). The recently passed One Big Beautiful Bill Act (OBBBA) finally delivers that victory. Effective Jan. 1, 2026, DPC arrangements will no longer be considered disqualifying health coverage for HSA purposes.
This is, on its face, a landmark achievement. It treats DPC membership fees — capped at a reasonable $150 a month for an individual — as a qualified medical expense, not an insurance plan.1,2 This single change unlocks a vast market of millions of Americans with high-deductible health plans, giving them a powerful new way to access comprehensive, relationship-based primary care. For physicians, it offers a path away from the burnout of fee-for-service bureaucracy and toward a more sustainable and patient-focused practice model.
But this victory is dangerously deceptive. It is a beautiful, gilded cage built in the middle of a collapsing ecosystem. While the OBBBA hands DPC a powerful new tool with one hand, it dismantles the rest of the health care safety net with the other.
The same law is projected to strip health insurance from an estimated 12 million Americans through massive cuts to Medicaid and the Affordable Care Act. This will not happen in a vacuum. The newly uninsured will still get sick, but they will delay care, arriving in emergency rooms with more advanced and costly conditions. This will trigger a tidal wave of uncompensated care — projected to cost physicians $24 billion and hospitals $63 billion over the next decade.2,3
A pyrrhic victory for physicians?
This is where the gilded cage slams shut. DPC practices do not exist on an island. They depend on a stable network of specialists and hospitals for referrals and escalations. What happens when a DPC patient needs a colonoscopy, a cardiac stress test, or an urgent surgical consult? They are sent to the very specialists and hospitals that will be buckling under the financial strain of uncompensated care.
When local hospitals are forced to close service lines, lay off staff, or shut their doors entirely — as many health care organizations predict will happen — a DPC membership becomes a ticket to a broken system. The promise of better primary care is undermined if there is no reliable specialty or hospital care to back it up.
The OBBBA’s gift to DPC is a classic Faustian bargain. It offers a clear and immediate business opportunity in exchange for systemic instability that threatens the viability of the entire health care community. True innovation cannot flourish in a system facing financial collapse. Unless we address the profound, indirect harms of this legislation, the long-awaited victory for Direct Primary Care may prove to be a hollow one indeed.
Hemant Kalia MD MPH FIPP is Consultant, Interventional Pain & Cancer Rehabilitation Medicine; CEO & Chief Medical Officer, Savya Neuroscience Institute; and President & CEO, C.R.I.S.P Center for Research & Innovation in Spine & Pain.
1https://www.ralaw.com/media/insights/alert/blog_post_or_one_big_beautiful_bill_a_boon_for_concierge_medicine
2https://www.congress.gov/bill/119th-congress/house-bill/1/text
