HSAs Are Good. HSAs Plus Direct Care Are Better.

I've admired Sally Pipes for more than 20 years. In a recent Washington Examiner piece, she pushes back on a Georgetown proposal that would cap deductibles and, by the authors' own description, sunset health savings accounts. She's right. Killing HSAs is backward.

She cites a study of more than 76,000 people at 709 employers. HSA enrollees spent roughly 5% to 7% less on health care. That's real money.

But here's my worry. The average family premium for job-based coverage is now nearly $27,000, per KFF. ACA benchmark premiums rose about 22% for 2026, per the Urban Institute. A lot of families pay the premium and have nothing left to put in the account. Telling them to save more can feel a little like "let them eat cake." To her credit, Sally suggests targeted help for lower-income households. I'd add one more tool.

Direct primary care.

One flat membership. Unlimited visits. No copays. At our clinics, meds and labs at wholesale, often a small fraction of retail. Procedures that would cost hundreds elsewhere, included.

That changes what an HSA dollar buys. Same dollar, many times the care.

And it's now official. Since January 1, 2026, people in a qualifying DPC arrangement can contribute to an HSA and pay the membership with HSA money, up to $150 a month for an individual.

I am not anti-insurance. Keep a policy for the wreck, and pair it with an HSA. Then let direct care handle the everyday.

HSAs give patients the dollar. Direct care makes the dollar worth something.

Sources: Sally Pipes, Washington Examiner: www.washingtonexaminer.com/restoring-america/faith-freedom-self-reliance/4744997/want-cheaper-health-insurance-dont-kill-hsas-preserving-low-premium-coverage/ KFF 2025 Employer Health Benefits Survey: www.kff.org/health-costs/annual-family-premiums-for-employer-coverage-rise-6-in-2025-nearing-27000-with-workers-paying-6850-toward-premiums-out-of-their-paychecks/ Urban Institute, 2026 ACA premiums: www.urban.org/research/publication/understanding-extraordinary-increase-aca-premiums-2026 IRS, HSA + DPC guidance: www.irs.gov/newsroom/treasury-irs-provide-guidance-on-new-tax-benefits-for-health-savings-account-participants-under-the-one-big-beautiful-bill

$15,728 vs. $5,900: What Insurance Did to the Price of Having a Baby

The median in-network cost of a vaginal delivery in the U.S. is $15,728. That's FAIR Health data, reported by Becker's Hospital Review. It went up 3.6% in a year.

In-network is supposed to be the discount. So I looked up what an uncomplicated birth costs when nobody bills insurance.

In Utah, the in-network median is $13,083. Birthing Your Way in Lehi posts $5,900 cash. That includes prenatal visits, the birth, and postpartum visits.

In Texas, the in-network median is $13,698. The Addice Birth Center near Houston posts $7,900 for prenatal care, the birth center, labor and birth, newborn screenings, and six weeks of follow-up.

In Arizona, the in-network median is $13,563. Valleywise Health, a public hospital in Phoenix, publishes a package for uninsured Arizona residents. A normal vaginal delivery with prenatal care, physician fees, and up to two hospital days runs $6,500, or $5,400 paid up front.

I am not shocked. When you take out the claims, the codes, and the network contracts, there's less to pay for.

To be fair, these prices are for low-risk, uncomplicated births. Complications cost more. Your out-of-pocket depends on your plan. And a median and a package price don't count every line the same way.

But the pattern is hard to miss. The "discounted" insured price runs about 1.7 to 2.5 times the posted cash price, and that's before a year of premiums.

That's the emperor's new clothes. We all agree insurance makes care affordable. For predictable care, it hasn't for a long time.

I am not anti-insurance. Keep a policy for the wreck: the emergency C-section, the NICU. A healthy, planned birth is about as predictable as medicine gets. It deserves a price on the door.

Direct primary care works the same way for everyday care. One membership. No copays. Wholesale meds and labs. A doctor who answers the phone.

$5,900 is a price. $15,728 is a system.

Sources: Becker's Hospital Review, The cost of giving birth in every state: www.beckershospitalreview.com/finance/the-cost-of-giving-birth-in-every-state/ Birthing Your Way pricing (2026): birthingyourway.com/pricing/ The Addice birth package (2026): www.theaddice.com/midwife-services-packages/ Valleywise Health maternity package (form rev. 2023): valleywisehealth.org/wp-content/uploads/2024/06/Form-45546-Maternity-Package-State-of-AZ-2023.02-REDLINE.pdf

5 Days, 3 Insurance Plans, and 1 Missing Diagnosis Code

5 days.

That is how long Kenney Blewett waited on a nebulizer medication his pulmonologist prescribed on June 2. He had COPD. The flare-ups were coming more often, and he called them "the scariest thing in the world." 2 days after the appointment, Walgreens emailed: the prescription was delayed "due to an insurance issue that we're working to resolve." On June 7, after another flare-up, he died by suicide. Lauren Sausser told the story for KFF Health News last week.

Nobody can say the delay caused his death, and his wife, Cindy, doesn't claim it did. He had struggled with his mental health for a long time. What she wants is an answer to a simple question: what happened to the prescription? Months later, she still doesn't have one.

Look at what she was up against. Medicare Part A and B. A private Part D drug plan. A Medigap supplement. 3 sets of rules for 1 man. The pharmacy said prior authorization. But the drug was a nebulizer liquid, one of the few that bill to Part B as durable medical equipment, not Part D. Medicare said it had no record of a Part B claim. A pharmacy supervisor later said the prescription went in without a diagnostic code, and a request was faxed to the doctor's office that same day. The office said it never saw the fax. The drug plan's parent company would not answer questions.

One missing code. One fax nobody saw. 5 days.

I am not shocked, and that is the problem. Every doctor reading this has lived some version of it. The prescription is not a medicine anymore. It is a claim. And a claim has to travel through a pharmacy queue, a billing category, a code field, and a fax machine before anyone asks whether the patient can breathe tonight.

This is not about one bad pharmacist or one sloppy front desk. A COPD Foundation advocate told KFF that Medicare has become "so complex and convoluted" that even office staff and pharmacists misunderstand it. And Medicare is now piloting AI prior authorization in 6 states, Texas included. More gates are coming, not fewer.

Direct care cannot fix all of that. Medicare patients still need Medicare, and some drugs still have to go through insurance. But in a direct care practice, a stalled prescription is a text message, not a mystery. The patient has my number. The pharmacist can reach me the same day. Many common medicines we dispense at wholesale, in the office, before the patient walks out. When there is no claim in the middle, there is nobody to lose the fax.

In Texas, where the Blewetts live, even that last step is harder. Texas is one of the states that restricts direct primary care physicians from dispensing medicine to their own patients, and the DPC Coalition is pushing to change it.

I am not anti-insurance. Keep a policy for the wreck. But a sick man asking his wife every day whether his medicine is ready is not a paperwork problem. It is a question somebody should be able to answer in 5 minutes.

5 days is not an insurance issue. It is what happens when everyone touches the prescription and nobody owns the patient.

If you or someone you love is struggling, call or text 988, the Suicide & Crisis Lifeline.

Veterinary Prices Climbed More Than 60% After the Roll-Ups

A decade ago, fewer than 10% of American veterinary practices were corporate-owned. Then the buyers showed up. Mars, private equity, the same MSO paperwork human medicine already perfected. Today the consolidators own roughly a quarter of primary-care clinics and about three-quarters of specialty and emergency hospitals. Together they take about half of all veterinary revenue. Your dog's bill climbed with them. Veterinary service prices rose more than 60% over the past decade.

I am not shocked. The structure was borrowed from us. A management company owns the building, the staff, the schedule, and the bank account. A clinician owns the practice on paper. The fee routes the profit upstairs. The name on the door stays warm and local. The invoice does not.

Production pay. More tests. More wellness plans. One emergency vet described prices rising 20% in a single year after a sale. That is not better medicine arriving overnight. That is a spreadsheet discovering a leash.

I am not anti-insurance. Keep a policy for the wreck. I am anti a clinic that got worse on purpose while pretending nothing changed. Human medicine already ran this play on doctors. Direct care is the other door. Flat monthly fee. Your doctor's name on the door. The number on the door is the number you pay.

60% is not inflation. It is what happens when care becomes a flippable house.

One Medicare Opt-Out Still Closes Every Other Door

Right now Medicare opt-out is all or nothing.

If you opt out so your Direct Primary Care practice can take Medicare patients on a flat fee, that same decision follows your NPI into every other room. Hospitalist shifts. Hospice. Skilled nursing. Locums. Outside of emergency and urgent care exceptions, you cannot bill Medicare anywhere else. CMS is explicit: the choice is not selective.

That is the rule Resolution 504 puts in front of the AAFP Congress of Delegates this October. The New Mexico Chapter asked the Academy to fight for a partial opt-out by practice setting — keep the membership model in one door, keep Medicare billing in another. The AAFP puts the fiscal note at $27,000 and the political risk at low. Passing it only makes it Academy policy. Changing the Social Security Act is still Congress.

I am not shocked. Most physicians wear more than one hat. A 3-day DPC panel and 2 hospitalist days is how a lot of towns keep both doors open. Force the all-or-nothing choice and the hospital loses the moonlighter, the hospice loses the weekend coverage, and fewer doctors ever open the membership practice in the first place.

DPC doctors are now more than 11% of AAFP membership — the fastest-growing sector. They know the rule in their bones. One opt-out should not erase every other role that still serves Medicare patients who are not on a membership.

I am not anti-insurance. Keep a policy for the wreck. I am anti a paperwork rule that makes Direct Primary Care harder to staff while seniors still need a hospitalist down the hall. We take care of patients for a flat monthly fee. No claim. No network. The number on the door is the number you pay.

One opt-out is a decision. All or nothing is a shortage wearing a regulation.

Source: www.mydpcstory.com/post/aafp-resolution-504-partial-medicare-opt-out-dpc