When the HSA rule change went into effect on January 1st of this year, the DPC community had been anticipating it for so long that it was almost hard to believe it was actually happening. For more than a decade, one of the single most common objections from prospective members was the tax penalty they effectively took by paying a monthly membership fee out of post-tax dollars while still being forced to maintain a high-deductible health plan with an HSA they could not use for primary care. That friction is now gone for practices that have structured their memberships correctly, and we are far enough past the rule change to have a real sense of what is and is not working for operators on the ground.
WHAT THE RULE ACTUALLY CHANGED
The short version for anyone who has not been paying close attention is that, as of January 1, 2026, having a DPC membership no longer disqualifies a patient from contributing to a Health Savings Account, and monthly membership fees can in most cases be paid from the HSA itself. The rule has specific requirements around how the membership is structured and what services it can include, and practices that want to take full advantage of it need to make sure their membership agreements are drafted to comply with the final guidance from Treasury. Most operators we have talked to worked with their healthcare attorneys in late 2025 to review their agreements and make the handful of changes needed to be comfortably on the right side of the rule, and the cost of that legal review has been one of the smaller line items in their annual practice operations budget.
WHAT PRACTICES ARE SEEING IN THEIR NUMBERS
The clearest signal in the first ninety days has been in retention. Several operators have told us that their month-over-month churn for January, February, and March ran noticeably lower than the same period in 2025, and the common explanation is that marginal members who might otherwise have dropped their membership during a tight financial month simply routed their next payment through their HSA and stayed enrolled. Retention is not a particularly glamorous metric but it compounds dramatically over time, and a practice that shaves even half a percentage point off its monthly churn ends up with meaningfully more members at the end of the year than one that did not.
New patient acquisition has been a more mixed story. Practices that proactively marketed the HSA eligibility to their local employer contacts and their existing members saw the biggest lift, with several operators reporting double-digit percentage increases in new signups during the first quarter compared to Q1 2025. On the other hand, practices that expected the rule change to drive a passive influx of new members without meaningful marketing effort have mostly been disappointed, because general public awareness of the change is still quite low and most prospective patients who would benefit from the new eligibility rules have no idea the rule even changed.
WHAT MEMBERS ARE ACTUALLY ASKING ABOUT
One of the more interesting operational surprises for practices that have opened up HSA payment as a new membership option is how many administrative questions members have about how it actually works in practice. The top three questions we have heard from operators are some version of "can I pay retroactively from my HSA for the months I already paid out of pocket," "does my spouse's HSA count or does it have to be mine," and "what happens if I change employers and my new HSA administrator is different from my old one." Practices that have put together a simple one-page FAQ for their members have significantly cut down on the volume of these questions reaching the physician directly, and we would recommend doing this if you have not already because it is the kind of small operational investment that pays back quickly.
THE EMPLOYER ANGLE IS WHERE THE REAL LEVERAGE SITS
The most underappreciated consequence of the rule change, at least based on what we are hearing from brokers and employer-focused operators, is how much easier it has become to sell a DPC-plus-HDHP package to small and mid-sized employers. Before January 1st, offering a DPC benefit alongside a high-deductible health plan required a carefully worded explanation of why the combination did not jeopardize employees' HSA eligibility, and the explanation often involved caveats that made benefits brokers uncomfortable. Now the pitch is dramatically simpler, the risk profile is cleaner, and several operators with employer-focused practices have told us that their first quarter contract signings ran well ahead of their internal projections.
For practices that have not yet built an employer side to their business but have thought about it, this is probably the best moment in the last decade to seriously consider pursuing that channel, because the regulatory friction that used to scare off mid-sized employers has largely evaporated and the remaining work is mostly about education and sales rather than legal structuring.
THE BOTTOM LINE AT 90 DAYS
Ninety days is not enough time to know the full long-term impact of the HSA rule change, but the early signals are directionally positive and broadly consistent with what the DPC community hoped would happen. Retention is stronger, employer conversations are faster, and the practices that have leaned into marketing the change to their existing and prospective members are seeing the clearest lift in their numbers. The practices that have not are mostly seeing the rule change as a modest but welcome improvement rather than a transformational event, which is probably the right framing. As with most things in DPC, the rule change gives you a better set of ingredients to work with but you still have to actually do the cooking.