Recent statements from the current administration have revived a policy framework that would place healthcare affordability dollars into individual-controlled accounts rather than routing funds through insurers or employer-sponsored benefit structures. Still at the framework stage and requiring legislative action, the architecture being explored signals a potential shift in how healthcare purchasing power flows through the system.
Whether or not this specific framework advances, it highlights a broader direction of travel already underway. Healthcare spending authority is moving closer to the individual. When control of dollars shifts, market incentives reorganize. For payers, platforms, provider networks, and emerging care models, the central question is not whether this proposal becomes law. The question is who owns the infrastructure that will sit between consumer wallets and care delivery.
In this context, infrastructure refers to the payment rails, enrollment flows, benefit wallets, and navigation platforms that sit between consumer spending authority and care delivery.
From pooled purchasing to individual wallets
For decades, healthcare purchasing has been dominated by pooled risk and centralized procurement. Employers selected plans. Insurers built networks. Patients consumed care with limited price visibility. That distribution architecture is changing. More than half of commercially insured Americans are now enrolled in high deductible health plans. Health Savings Account assets exceed $100 billion and continue to grow annually. Cash-pay utilization has steadily increased over the past decade.
These are not marginal trends. They reflect a structural shift toward consumer-directed spending. Proposed federal frameworks that deposit affordability dollars into individual-controlled accounts accelerate this trajectory. But shifting dollars is only the first-order change. The second-order effect is the rapid emergence of new intermediaries competing to manage those dollars.
In any consumer market, whoever owns the payment rails, enrollment flows, and navigation experience owns the customer relationship. Healthcare will be no exception.
The rise of the health wallet economy
Account-based affordability mechanisms create a new category: the healthcare wallet. Once individuals hold defined healthcare budgets, platforms move quickly to offer spending interfaces, curated marketplaces, subscription bundles, and guided purchasing experiences.
This is already visible in benefit administration technology, HSA custodians, pharmacy benefit platforms, and emerging care marketplaces. As more dollars sit in consumer-controlled accounts, competition intensifies to become the default interface through which care is selected and purchased.
The consequence is straightforward. Care models that do not control consumer touchpoints risk being abstracted behind platform layers. Clinical differentiation alone does not prevent disintermediation. Infrastructure ownership does.
Direct primary care enters a retail market
Direct Primary Care and concierge medicine sit at the intersection of this transition. Their pricing transparency, subscription design, and direct access models align naturally with consumer purchasing behavior. As individual-controlled spending expands, membership-based care models become easier for households to evaluate and adopt.
But retail alignment introduces retail risks.
Retail DPC relies on household discretionary income. Household budgets are sensitive to inflation, competing subscription expenses, and perceived value. Churn becomes a structural feature. Continuous acquisition replaces episodic referral growth. In retail markets, strong clinical care is table stakes. Brand trust, frictionless payments, and consumer experience capture value.
Many physician-owned DPC practices have built clinically efficient care delivery systems inside a healthcare distribution environment that historically protected them from retail competition. A consumer wallet economy removes that insulation.
Commoditization pressure and platform aggregation
As consumer-directed spending expands, aggregation follows. Platforms emerge to bundle DPC memberships, telehealth access, pharmacy services, and care navigation into unified offerings. Broker and advisor models evolve from plan selection toward marketplace curation. Network assemblers position themselves between individual wallets and provider supply.
In that environment, independent care practices risk becoming interchangeable supply-side participants in someone else’s marketplace. This is not a hypothetical threat. It is a pattern seen across travel, financial services, and retail. The owner of the transaction layer captures long-term leverage.
The DPC sector has focused heavily on clinical model innovation. The next phase will require equal attention to distribution control.
Where employer-sponsored models still matter
Employer-sponsored care arrangements retain a structural advantage. Organizations pool risk, subsidize access, and stabilize revenue. Even as individual-controlled funding expands, employers remain positioned to curate care ecosystems, provide decision-support infrastructure, and reduce household budget sensitivity.
This means two parallel markets will coexist. A retail-driven DPC segment characterized by higher growth and higher volatility. An employer-sponsored DPC segment characterized by steadier revenue and lower churn. Platforms that can serve both purchasing pathways will be best positioned for scale.
Infrastructure determines value capture
It is important to remain precise. The current federal framework represents a proposal, not enacted law. No implementation timeline exists. Legislative processes will determine whether and how such mechanisms materialize.
But the underlying structural movement toward consumer-directed healthcare spending is already in motion. Policy frameworks accelerate trends. They do not create them from scratch.
As healthcare dollars move closer to individuals, the industry enters a new competitive phase. Value will accrue less to those who deliver care and more to those who own how care is selected, purchased, and experienced.
The market test ahead
Shifting healthcare dollars into individual-controlled accounts would mark an inflection point. But even without full policy execution, consumer wallet economics are expanding. The race is now on to build the infrastructure layer between individual spending authority and care delivery.
In the next phase of healthcare transformation, infrastructure will decide who wins.
Photo: Overearth, Getty Images
Dana Y. Lujan, MBA, CHFP, CRCR, is founder of Wellthlinks, a healthcare advisory firm that connects providers and employers to design compliant, innovative care models. With more than 20 years of experience in healthcare operations, contracting, and compliance, she has advised health systems, physician groups, and employers on strategies ranging from value-based contracting to direct primary care adoption. Her thought leadership has been published on KevinMD and Medium, where she writes on innovation, compliance, and employer health strategies. She is passionate about building sustainable models that improve access, reduce costs, and strengthen trust between employers, providers, and employees.
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