43% of Marketplace Enrollees Now Have HSA-Eligible Plans. Here's Why DPC Practices Should Care.

Industry News by DPC Insider
#HSA#marketplace enrollment#bronze plans#OBBBA#patient access#ACA
Sources: Exchange Coverage Remains Near Record High as 23.1 Million Enroll in 2026 · Bronze ACA Plan Enrollment Surges Across States · 8 Things to Watch for the 2026 ACA Open Enrollment Period (KFF) · Devenir HSA Newsletter: April 2026 · A Big, Beautiful Break for HSAs: IRS Guidance on the OBBBA (Groom Law Group)

Two percent. That’s the share of HealthCare.gov consumers who selected an HSA-eligible plan during the 2025 open enrollment period. In 2026, that number jumped to 43%.

If you run a DPC practice, that shift matters more than almost anything else that happened in healthcare this year. Here’s why.

The Bronze Surge

The 2026 ACA open enrollment period brought 23.1 million sign-ups, down about 5% from 2025. But the real story isn’t the total. It’s where people landed.

Bronze plan enrollment surged 26% nationally, climbing from 7.3 million to 9.2 million enrollees. Bronze plans went from 30% of all marketplace selections to 40%. Silver plans, which had dominated for years, dropped from 56% to 43%.

The trigger was straightforward. The enhanced premium tax credits from the Inflation Reduction Act expired. Those subsidies had made silver and gold plans affordable for millions of people. Without them, premiums climbed, and consumers shifted to the cheapest option available: bronze.

Some states saw dramatic swings. Texas bronze enrollment jumped 84%, from roughly 705,000 to nearly 1.3 million. Mississippi rose 77%. New Jersey climbed 60%. Only five states and the District of Columbia saw bronze enrollment decline at all.

Why This Connects to DPC

Bronze plans are high-deductible by nature. They cover about 60% of costs on average, which means enrollees pay significantly more out of pocket before insurance kicks in. For routine primary care visits, many bronze plan holders are effectively paying cash.

That’s where two provisions of the One Big Beautiful Bill Act intersect.

First, the law made all bronze and catastrophic marketplace plans automatically HSA-eligible, regardless of whether they previously met the technical definition of a high-deductible health plan. Before 2026, only about 2% of marketplace enrollees had HSA-eligible coverage. Now roughly 43% do. That’s close to 10 million people on HealthCare.gov alone who can open or contribute to a health savings account.

Second, the same law made DPC membership fees a qualified HSA expense. Starting January 1, 2026, patients can use their HSA funds tax-free to pay for DPC memberships, as long as the practice charges no more than $150 per month for individuals or $300 per month for families.

Put those together: millions of people just moved onto high-deductible plans where they’re paying cash for routine care. Those same people now have HSA accounts. And those HSA dollars can go directly to a DPC membership.

The Fine Print Still Matters

The opportunity is real, but the rules aren’t simple.

The IRS set the monthly fee caps at $150 for individuals and $300 for families. Most DPC practices fall within that range. Individual memberships typically run $70 to $100 per month, with family rates between $150 and $300. But practices at the higher end of the spectrum, or those offering expanded services, might bump up against the ceiling.

There’s a critical nuance: if a practice charges above the cap, patients can still use HSA funds to pay the fee. But they lose the ability to make new HSA contributions while enrolled. That’s a meaningful trade-off that could steer patients toward practices priced under the limit.

The IRS also hasn’t clearly defined what counts as “primary care services” under these arrangements. Groom Law Group flagged this gap in their analysis of Notice 2026-05, noting that the guidance excludes procedures requiring general anesthesia, prescription drugs other than vaccines, and non-ambulatory lab services, but doesn’t spell out what’s included. For DPC practices that offer a broad scope of in-office services, that ambiguity creates compliance questions that don’t have clear answers yet.

On the employer side, the rules add another layer. Employer-paid DPC fees can’t be reimbursed from employee HSAs, and DPC fees don’t count toward HDHP deductibles or out-of-pocket maximums. Employers can still offer DPC as a benefit, but structuring it alongside HSAs requires careful plan design.

The Devenir HSA Newsletter warned in April that the IRS interpretation of these provisions could “keep the OBBBA provision from working the way supporters in Congress intended, by creating confusion about what employers can do.” The public comment period on Notice 2026-05 closed March 6, and final Treasury regulations are still pending.

What This Means

The DPC movement has spent years arguing that the model works for ordinary people, not just affluent patients who can afford to pay cash on top of their insurance premiums. The 2026 marketplace shift is the strongest validation of that argument yet.

Nearly 10 million marketplace enrollees now have both the financial tool (HSAs) and the legal permission to spend those funds on DPC memberships. For practices priced under $150 per month, this removes what used to be one of the biggest objections patients raised: “I already pay for insurance. I can’t afford a membership on top of that.” Now they can pay with pre-tax dollars from an account specifically designed for healthcare spending.

If you’re running a DPC practice, you might want to start thinking about how you communicate HSA compatibility to prospective patients. For the millions of Americans who just landed on bronze plans with high deductibles and uncertain access to their primary care physician, a $75-a-month DPC membership paid with HSA funds could look like the most straightforward path to a doctor who actually has time for them.