DPC Is Exempt From Insurance Regulation in 34 States. ALEC Wants the Other Sixteen to Catch Up.

Thirty-four states have passed laws exempting direct primary care from insurance regulation. In the other sixteen, a DPC practice operates in a legal gray area: probably fine, never quite official. ALEC, the conservative policy group that drafts model legislation for state lawmakers, wants those remaining states to catch up.

Miranda Spindt, director of ALEC’s Health and Human Services Task Force, made that case in a June 29 op-ed published in RealClearHealth. Her argument: with ACA Marketplace enrollment down 1.2 million and another 5.8 million people projected to lose coverage this year, states should make room for alternatives.

The Three-Part Case

Spindt doesn’t present DPC as a standalone fix. She describes a three-part arrangement: DPC for routine visits, health care sharing ministries for large unexpected bills, Farm Bureau health plans for broader coverage at lower cost.

She uses herself as the example. Her healthcare runs through a DPC clinic and a health share plan, and she says it costs 60% less than traditional insurance. Her DPC membership covers unlimited appointments with no copays for routine and urgent care.

Spindt cites data showing that in 2022, 3% of family physicians practiced in a DPC model. By 2023, that number hit 11%. Health care sharing ministries grew from 160,000 members to 1.5 million between 2014 and 2021. Tennessee’s Farm Bureau Health Plans serve over 200,000 members and reportedly cost 30 to 50 percent less than Marketplace coverage.

Where States Stand

DPC is legal everywhere. You can open a membership-based primary care practice in any state. But the legal clarity varies.

Thirty-two states have enacted DPC-specific statutes, according to Patient Options, which maintains a state-by-state tracker updated in March 2026. Those laws spell out what a DPC agreement is and confirm it’s not an insurance product. Spindt’s count of 34 exemptions suggests a couple more states have achieved the same result through regulatory guidance rather than formal statute.

The states still without DPC-specific legislation include California, Illinois, Massachusetts, Pennsylvania and Wisconsin, all states with large physician populations where regulatory clarity would carry real weight.

In practice, the absence of a DPC law doesn’t block anything. No state insurance commissioner has treated a DPC agreement as insurance in the years these models have been operating. But the ambiguity creates friction for physicians writing a business plan, for investors evaluating the model and for employers deciding whether to offer DPC as a benefit.

Why ALEC Matters Here

ALEC drafts model legislation that state lawmakers can introduce with minimal modification. The organization claims more than 2,000 state legislators as members. When its health task force director writes a public op-ed calling for DPC exemption laws, it signals that model bills are coming in upcoming state sessions.

Spindt’s piece also pushes for health care sharing ministry exemptions, currently in place in 31 states, and Farm Bureau health plan authorization, currently limited to just 14 states. The DPC push is one piece of a broader ALEC effort to build parallel healthcare options outside the ACA framework.

What This Means

If you’re running a DPC practice in one of the 34 states with an exemption law, your regulatory footing is clear.

If you’re in one of the sixteen states without one, the ALEC push matters. State-level DPC bills tend to pass with bipartisan support once they’re introduced, because they cost the state nothing and don’t disrupt existing insurance markets. The obstacle has been awareness, not opposition, and a coordinated push from a well-connected political organization could change that.

For the DPC movement, the Spindt op-ed signals where the conversation has moved. The task now is getting the remaining sixteen states to match what 34 have already done.