Helping those patients most dependent on DPC means defeating the DPC/HDHP/HSA “fix”.

Plus, two more reasons to reject the “fix”.

Direct Primary care clinicians and advocates often point out, accurately, that they serve a broad socio-economic range of patients. The range is well illustrated by a pair of oft-appearing themes, “concierge care for the middle class” and “affordable care for those who fall between the cracks”. In turn, the themes are reflected in two almost polar opposite insurance profiles for each of which DPC presents a solution: those in the middle class with sound, high-deductible insurance policies and those with low incomes for whom standard health insurance of any form is beyond their limited means.

The uninsured are not a tiny sliver of DPC subscribers. A recent survey put their numbers at about a quarter of DPC patients, and many DPC docs say 30-40% in their own practice. Indeed, a January NPR piece on the use of DPC by HDHP holders immediately prompted the DPC Alliance to vigorously advise the public that the economically disadvantaged are the “focus” of quite a few direct primary care practices.

The middle class HDHP group predominantly join DPC for mixed reasons of economy and concierge-like convenience, making a relatively good situation even better. Many of them — surely those with the most discretionary spending ability — are able to save. The low income uninsured on the other hand, enter DPC subscriptions to make the best of a bad situation, and they have essentially nothing to bank.

The Primary Care Enhancement Act and similar initiatives seek to provide substantial tax subsidies for direct primary care subscription fees, but these flow only to those who have BOTH high deductible health insurance plans AND enough income to be able to save some. But this kind of “fix” does less than nothing to those on the other side of the income/insurance divide; for them, the “fix” actually makes things worse.

Economics 101 teaches that government subsidies increase the price of the subsidized goods or services. The middle-class DPC members with insurance may, or may not, see net benefit from a subsidy; since the supply of family physicians is tight, most of the subsidy will probably flow to the providers as increased subscription fees. In any case, what low income DPC members will get from a “fix” is higher subscription fees.

Already priced out of standard insurance and forced into direct primary care, they will be pressed even harder. And some will find themselves forced out of direct primary care.

Subsidies for middle class savers (and/or their DPC physicians) may or may not be warranted by the purported virtues of direct primary care. But subsidies that are directed toward DPC’s financially soundest subscribers should not come at the cost of pushing DPC’s most financially desperate and loyal patients out of their best chance of quality care. Almost any other way of investing federal resources in DPC would be more fair and better targeted.

Do no harm.


But wait, there’s more.


Bonus # 1: The DPC/HDHP/HSA fix aggravates an income inequity among the insured population that is already baked into the DPC cake.

The signal feature of the DPC world is that direct primary care clinics do not take insurance, so entry is overwhelmingly on a cash only basis. DPC is effectively unavailable to anyone who is insured but does not have the financial resources to buy an additional layer of primary care services that does not draw insurance reimbursment or even get credited against a deductible. By the same considerations, DPC becomes increasingly available as the income ladder is ascended.

When that socioeconomic reality is coupled to DPC emphasis on small patient panels and easy access, the resemblance of DPC to concierge medicine undercuts any argument for relaxing HSA rules on DPC. In fact, the HSA break amounts to a regressive subsidy that supplements funds being spent on DPC; this has the effect of growing the rate at which DPC becomes increasingly available as the income ladder is ascended.


Bonus # 2: the DPC/HSA fix aggravates the rural health care provider shortage

DPC advocate claims of being all things to all men sometimes take the form of, “DPC is the best hope for primary care in rural areas.” But the effect of a DPC/HSA fix will be to drive DPC physicians toward areas where middle class HDHP savers are in large proportion and away from rural areas where there are plenty of the poor and disproportionately few in the middle class.

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