The OBBBA Let Millions Pay for DPC with Their HSA. Rural Medicare Patients Weren't Included.

The One Big Beautiful Bill did something real for Direct Primary Care. Starting January 1, 2026, Americans who pair a DPC membership with a high-deductible health plan can pay monthly fees directly from their HSA. For the first time, a DPC membership is a qualified medical expense under federal law.

But there’s a gap. And a prominent policy economist just put a number on who’s in it.

The 65 million Americans on Medicare and the 80 million enrolled in Medicaid can’t use HSAs the same way. For many of them — particularly in rural communities where primary care has quietly disappeared over the past decade — DPC is exactly the kind of medicine that could work. The payment pathway doesn’t exist yet.

John C. Goodman, president of the Goodman Institute for Public Policy Research, made that case in a May 9 op-ed in The Hill. The piece was framed around rural healthcare modernization broadly — telemedicine licensing, scope-of-practice laws, drone delivery — but his DPC point was specific: HSA-funded DPC should extend to Medicare and Medicaid beneficiaries, not just working-age adults with employer coverage.

What the Rural Access Gap Actually Looks Like

Goodman’s piece opens with a striking number: 96% of Americans live within 90 minutes of a full-service hospital. The infrastructure for quality care largely exists. What’s missing is the regulatory permission to use it differently.

Rural primary care shortages aren’t simply about geography. They’re about economics. A rural practice with 1,200 fee-for-service patients, 15-minute appointments, and two full-time billing staff can barely break even. The margin disappears. Doctors leave. Practices close. Patients start driving 45 minutes for an appointment that was booked six weeks ago.

DPC changes those economics. A solo physician with a panel of 400-600 members, each paying a monthly fee, can spend real time with patients without the overhead that makes rural fee-for-service unworkable. No prior authorizations. No billing staff. Predictable revenue.

The challenge: the people most likely to live in rural areas without a primary care physician are elderly and low-income. They’re on Medicare. They’re on Medicaid. And the OBBBA, for all it changed, didn’t reach them.

What Goodman Is Proposing

Goodman cites Atlas.md in Wichita as a DPC example, noting the practice offers patients direct access for roughly $50 a month. He proposes extending HSA-like account mechanisms to Medicare and Medicaid — allowing beneficiaries to use government-provided accounts or credits to cover DPC membership fees, the same way HSA holders can now.

This isn’t a new idea in DPC circles. Colorado’s 2026 Medicaid-DPC pilot bill passed the state House before the Senate shelved it. The DPC Alliance has raised the Medicare angle at multiple advocacy events. What’s new is the framing: a nationally recognized health economist publishing in a major DC policy outlet and treating DPC alongside telemedicine and scope-of-practice as part of a coherent rural access agenda.

The OBBBA established a template. It set monthly fee caps at $150 for individual DPC memberships and $300 for families for HSA purposes. Congress has already decided DPC is a qualifying service. Extending that logic to Medicare and Medicaid beneficiaries is a separate fight — but the scaffolding is in place.

The Obstacles Are Real

Medicare is built around fee-for-service. The current bridge between Medicare and DPC — the Advanced Primary Care Management (APCM) monthly payment — runs alongside a DPC membership, not as a substitute for it. Letting Medicare beneficiaries use a DPC membership in place of traditional primary care billing would require statutory changes, not just regulatory guidance from CMS.

Medicaid is more fragmented. It’s a joint federal-state program, and every state administers it differently. Colorado’s failed pilot illustrated how Medicaid DPC experiments can stall even with House support behind them.

The equity question is also live. DPC works best when patients can reliably pay a monthly membership. For Medicaid beneficiaries living on low fixed incomes, even a $40-$50 monthly fee can be a barrier without a subsidy structure designed carefully enough to actually reach them. The goal isn’t to extend DPC to people who can afford to pay — it’s to extend it to people for whom rural fee-for-service is already failing.

What This Means

If you’re a DPC physician practicing in a rural or semi-rural county, this policy debate matters directly to your practice economics. A meaningful portion of your surrounding community is likely on Medicare or Medicaid. Right now, those patients either can’t join your practice or pay out of pocket at the full membership rate, which limits who you can realistically serve.

If the policy environment continues moving in the direction Goodman is arguing, that could change. It won’t be fast. Medicaid reform moves at state speed, and Medicare reform moves at Congressional speed. But the OBBBA created a beachhead, and the pressure to extend DPC’s advantages to older and lower-income rural patients is building in ways it wasn’t two years ago.

If you’re a resident weighing a rural DPC practice, the question of whether Medicare and Medicaid patients can participate isn’t academic — it’s central to whether the numbers work. A panel of commercially insured, working-age adults may not be realistic in many rural counties. That makes the policy trajectory one of the things worth watching alongside your state’s DPC legal framework.

The OBBBA was the first clear federal recognition of DPC as a legitimate payment model. Whether Congress takes the next step — extending that recognition to the Americans rural healthcare is most visibly failing — is the policy story DPC physicians should be following.