$1,200 a Year to Your Doctor, and Your Deductible Acts Like It Never Happened

Picture a patient I'll call Dana. She runs a small bookkeeping office, buys a high-deductible plan, and pays her direct care doctor $100 a month. That's $1,200 a year for visits, texts, labs at cost, and someone who knows her name.

This year, for the first time, Dana can pay that membership out of her health savings account without losing the right to keep contributing to it. Congress fixed that. It was a real win, and it took years.

But here's the part nobody tells Dana at open enrollment. Under Treasury and IRS guidance, her insurance plan generally can't count a single dollar of that $1,200 toward her deductible or her out-of-pocket maximum. She spent the money on medical care. She spent it from a medical account. And the plan has to act as if it never happened.

Justin Leventhal of the American Consumer Institute put it plainly in RealClearHealth last week: Washington now lets a patient use tax-advantaged savings to spend $1,200 a year on primary care, "but requires the patient's health plan to act as though that $1,200 in healthcare spending never occurred."

That's not a small accounting quirk. KFF's 2026 employer survey found the average single deductible at a small workplace is $2,624. For Dana, $1,200 is nearly half of it. If it counted, her plan would start paying for the MRI or the specialist visit that much sooner. Because it doesn't, she's paying for primary care twice: once to her doctor, and again, in effect, when the deductible resets in January as if she'd never seen one.

Some states have made it worse. Maine got one thing right by saying a direct care membership isn't insurance. Then it barred those fees from being applied toward an insurance deductible at all.

I'll be honest about the fix, because it's a modest one. Nobody needs a new mandate. Leventhal's proposal is simply to let an insurer choose to credit direct care fees toward the deductible without the plan losing its HSA-qualified status. Insurers that want to build plans around direct care could. Patients who value that could buy them. Everyone else could ignore it.

That's how insurance is supposed to work. The membership handles the frequent, predictable stuff: the sinus infection, the blood pressure check, the refill. Insurance handles the big, rare, expensive stuff. Each does the job it's good at, and neither pretends the other doesn't exist.

Right now the rules pretend. They treat the most sensible money Dana spends all year, the money that keeps small problems small, as if it went nowhere.

Congress already did the hard part when it stopped penalizing people for paying their doctor directly. Finishing the job is one sentence of law. Count the care.

Until then, if you're comparing plans this fall, do the math the plan won't do for you. Add your membership to your premium and your deductible, and look at the whole number. A cheaper wrap-around plan plus a direct care doctor still wins for a lot of families. It would win for even more if the rules let the receipt count.

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