A New Plan to Save Primary Care Runs on a Subscription Fee. It Would Also Ban Other Basic-Care Insurance.

Primary care physicians leave their employers. They join groups that charge subscription fees for all basic care. No other insurance for that care is allowed.

That’s the outline health care journalist Ken Terry laid out in KevinMD on October 15, drawn from his new book. He concedes up front that “this may sound like a pipe dream.” The phrase “direct primary care” never appears in it. If you run a DPC practice, though, you’ll recognize the engine at once: a recurring fee, paid directly, that frees the physician from an insurer’s billing rules and a health system’s productivity targets.

The engine is familiar. The chassis Terry bolts it onto is something else, and the differences say a lot about what makes DPC work.

What Terry actually proposes

His starting point is employment. Terry writes that “between 30 and 33 states have corporate practice of medicine (CPOM) laws or regulations that, in theory, prohibit corporate employment of doctors,” and argues lawmakers should give those laws teeth, applied only to primary care physicians.

Freed physicians would then form “competing primary care groups of a certain size.” In his words, “These groups would charge subscription fees for all basic care, which would roll up to an annual budget for each group.” Patients would pick a group on its fees and its published quality and patient experience rankings. “Employers, the government, and consumers would split the cost of the subscriptions, depending on a person’s income.”

Then the line that turns a model into a mandate: “No other basic care insurance would be allowed, so primary care doctors would have little choice but to join a group.”

Separate “major medical” insurers would cover hospital care, post-acute care and expensive outpatient services. Terry also endorses a modified form of Maryland’s all-payer hospital rate setting.

His diagnosis is hard to argue with. The Physicians Foundation reports that less than 5% of total U.S. health care spending goes to primary care, and that nearly one-third of adults lack a usual source of it.

Where it parts from DPC

The first break is choice. AAFP describes DPC as “a meaningful alternative to fee-for-service (FFS) insurance billing” for family physicians, and notes that patients “choose to subscribe.” Terry’s design narrows that choice for physicians. With other basic-care insurance banned, he writes, they “would have little choice but to join a group.”

The second is scope, and it matters more than it looks. Terry wants primary care physicians “placed in charge of all basic care, including the lower levels of specialty care,” with each group delivering “high-quality care within a budget.” Putting a primary care group in charge of specialty care, inside a budget, reads more like a capitated health plan than a membership.

Federal law has already drawn a line here. When the One Big Beautiful Bill Act made DPC compatible with health savings accounts, it defined a direct primary care service arrangement narrowly. IRS Notice 2026-5 describes it as medical care “consisting solely of primary care services provided by primary care practitioners,” where “the sole compensation for such care is a fixed periodic fee.” The notice limits those practitioners to physicians in family, internal, geriatric or pediatric medicine, plus nurse practitioners, clinical nurse specialists and physician assistants.

The same notice excludes procedures requiring general anesthesia, prescription drugs other than vaccines and lab services not typically administered in ambulatory primary care. Its dollar line sets a boundary on the definition, and practices can still charge more. When aggregate fees run above $150 a month for one person, or $300 for an arrangement covering more than one (adjusted for inflation after 2026), the arrangement falls outside the definition. The notice says “there is no specific limit on the amount of the fixed periodic fee” for paying it from an HSA. What a patient in a pricier arrangement loses is the right to make HSA contributions while enrolled.

Whether the HSA rules would even matter in a world without other basic-care insurance is a separate question. The point is that the federal HSA definition of a subscription arrangement covers primary care only.

The third is size. The op-ed never says how large his groups would be, only “of a certain size,” ranked against each other on published metrics. The American Academy of Family Physicians puts the average DPC panel at about 413 patients, with monthly fees that generally range from $50 to $100.

What it borrows

Two pieces of Terry’s plan also describe how DPC already works. Patients pay a subscription fee, and they see the price before choosing. Terry argues that physicians running their own groups could “make their own financial and clinical decisions without interference from health care systems or insurance companies.”

Terry reached the same mechanism from the policy side, starting from what employment has done to primary care.

The Counterargument

Terry’s strongest reply would be about reach. A voluntary model serves the people who choose it and can pay for it, or whose employer pays. It can’t, on its own, give a usual source of care to the third of adults who lack one. If subscription primary care is the right engine, his plan says, it has to run for everyone, and everyone means compulsory, with income-based subsidies.

That argument holds on reach. DPC is still a choice that each physician and each patient makes, one practice at a time.

It holds less well on the physician’s side. Terry’s complaint about employed doctors is specific: “They would still be forced to see more patients per day than they’d like to, and their clinical autonomy would still be limited.” A group that lives inside an annual budget, competes on published rankings and draws part of its revenue from government subsidies answers to someone other than its patients again. In DPC Insider’s reading, that looks like a payer sitting in a different chair.

DPC physicians walk away from exactly that arrangement. The option to walk away is the feature a mandate can’t keep.