Listen to the Podcast here: What DPC Doctors can do in the wake of Medicaid Cuts
Summary: In this episode of DPC Pediatricians, Dr. Phil Boucher and Dr. Marina Capella respond to recent legislation — the “One Big Beautiful Bill” — which is projected to strip 12–17 million people, including millions of children, of Medicaid coverage. They explore how Direct Primary Care (DPC) pediatricians can step in to help fill this critical gap.
Welcome to DPC Pediatrician. We’re Dr. Phil Boucher and Dr. Marina Capella, two DPC pediatricians who are on a mission to share our love of direct primary care with you. Hey, everyone. Welcome back to another episode of DPC Pediatrician. Excited to chat today. Actually, today we have kind of a unique opportunity to talk about something that is timely
and topical. Often there aren’t a lot of moving pieces when it comes to direct primary care in terms of news or things like that. So we talk about all the different aspects. But right now, just this past month, the one big beautiful bill, I think it was called, ACT passed,
which stripped something like 12 million children of Medicaid coverage over the next 10 years. And we wanted to talk about how we as dpc pediatricians can be a part of that safety net because a lot of children we know are going to lose access we also have the notion or idea that there’s
probably going to be a lot of closures of children’s clinics and children’s hospitals or a reduction in services at least which may dramatically impact our listening audience because a lot of children’s hospitals run on Medicaid. And if all of a sudden all these children, they’re Medicaid and they’re losing their access, then the downstream consequences that affects training,
it affects private practice, it affects academics, it affects a lot of different areas. But we wanted to focus in and talk a little bit about this. And Marina actually wrote a fantastic blog post on the 4th of July on dpcpediatrician.com talking through different ways. So maybe Marina, you can set up for us a little bit about, okay,
a bunch of children are losing access. Well, DPC pediatricians are thought of often incorrectly as not really doing anything to help in the Medicaid realm anyways, even though you and I know that’s not true. And we see Medicaid patients in our practice for a variety of different things. What are some of the ways that we can,
as pediatricians in direct primary care, help that you talk about in your article as a place to start when it comes to helping with this shortfall and the loss of coverage for all these kits?
Absolutely. Yeah. This was something that I had been following in recent weeks, trying to figure out if this would pass and it seemed highly likely to pass. I thought it would be a good discussion for us to have. And like I said, like you said, I wrote that article. I have a couple of ideas.
And also first to clarify, somewhere between 12 and 17 million people are estimated to be losing Medicaid. It may not happen right away. I think a lot of the cuts have been delayed until 2026, maybe the middle of the year. Like right after midterm elections. Yeah, exactly.
It’s yet to be seen exactly how many people will lose Medicaid. That 12 to 17 million includes children. So I’m not exactly sure what percentage of that is children, but a lot of them are going to be children, right? So one of the first ideas that I talked about in the article was really just
offering flat fee visits. And I grew up in a family who was an immigrant family and didn’t have access to health insurance for various reasons because of the jobs that my parents worked and because of immigration status. And so I remember growing up most of my life without health insurance and without access. And my parents,
I don’t know if we would have qualified for Medicaid, but there’s certainly an attitude among many immigrant communities that they hesitate to use public services because of the whole public charge situation that if they were to apply eventually for immigration status or citizenship, then it would be viewed against them that, oh,
you were using public services and you’re just costing our country resources. But that aside, like, I remember my family, the psychology around money was very much the psychology of like, if we’re not going to use it, we’re not going to pay for it. Right.
So when we really needed things, my parents would figure out a way to come up with the money to pay for it. So one of my brothers fractured something one time when we figured out a way to pay for that. And my mom lost a toenail one time and we figured out a way to pay for that.
But they had been presented with this membership model that most of us do and say, oh, you’re going to pay whether or not you need to see the doctor that month. I think it’s a really hard sell for lower income communities. Right. So just psychologically, there’s a barrier.
And that’s where the flat fee visits really come in, because people when they really need an urgent visit or if they just really need their kid to get a sports physical or something like that they’re more likely to say what we
can pay that amount to get our kid what they really need right now right and so it just increases accessibility for more people wherever they are on the income spectrum i know i offer flat fee visits still i have priced them Somewhat higher, of course, for standard families,
but I also offer discounts if a family is in a really hard place. How about you, Phil? I know you offer flat fee visits. Tell me about what you think that has done for increasing accessibility to your practice.
Yeah, similarly, I think we’d have a lot of families that are in the same sort of boat that you were speaking to, too, where they might not qualify for whatever reason, but they need a checkup. They need to pay for vaccines out of pocket, but they want to get vaccines.
And so we do offer those one-time visits for families that are, for whatever reason, not able to go to their regular, like a regular primary care doctor, or they’re aware that we offer those. or they don’t have access to insurance for all the various reasons.
And so we do offer those one-time visits, some of them convert into members. And I think that that I think is surprising to a lot of people, but a lot of times they can do the math of being out of work to go sit at the doctor’s office for three hours for a quick
quick checkup or a sick visit or something like that. And they realize, hey, if I can get my care at this price per month and we get all the things that come with DPC, that it makes sense for them. And so we do those one-time visits as a way to make sure that patients have access
to a pediatrician, especially if they don’t have the insurance route to get into a regular office. And that’s something that we’ve always done. We don’t price it super high for acute visits. We kind of just have a flat fee for acute visits of $147 or those. And then for more complicated stuff,
we have a higher price if it’s ADHD or autism or something along those lines that we’ve talked about in other episodes. But that’s been a way that we are able to provide for families to get in and get seen for what amounts to, especially if you’re paying out of pocket, less
than going to their typical family doctor or pediatrician where it’s a fee-for-service practice where they’re going to get a 99214 for their visit and they’re going to pay out of pocket at the time of the visit. It is more cost-effective to come to us without insurance.
Definitely. Yeah, and I’ve had some families tell me that. I have similar pricing to you. If it’s like a 30-minute acute visit, it’s about $150. If it’s something longer, of course, that takes more time, it’s going to be more But families, a couple of families will just text me twice a year asking for that acute visit
because their kid is vomiting or their kid might have an ear infection. And and they’ve told me, I think one time I wasn’t available and I said, well, you can go to this Instacare, which is like our local urgent care system. and the family said well like last time we went it was really expensive we would
rather wait for an appointment with you so yeah there really is that price difference especially when these medical systems they’re trying to they’re trying to keep their practices afloat and so they’re trying to charge for as much stuff as they can it’s not just the visit it might be if they administered a medication or
if they did an x-ray or all of that stuff adds up and so we can definitely be more cost effective for many families and it can still work for us if we price ourselves accordingly.
Totally. What about ways that we’re able to help from a Well, for families that are obviously they’re, they’re on Medicaid, they’re losing their Medicaid coverage. Their money is stretched tight. You talked about this a little bit in the article about ways to offer a discounted
membership and I’ll share what we do and then would love to hear what you do in your practice. But we have always, since we opened said, we don’t want to just be for the rich people that, that, that all the different things that you could imagine that they want to have access to their pediatrician.
We want to be for everybody. And we’ve already been that for a lot of people for a lot of different reasons, but we’ve always held at least 20% of our patient panel for reduced price memberships just out of the good feels and goodness of helping those in the community and extending our blessings that we’ve gotten.
And so we’ve always had reduced fee schedule that people just ask for. And we then offer them, we don’t require payment stubs or pay stubs or something things along like that we just don’t have the bandwidth to be like checking people’s pay stubs we say we have these spots
available 30 60 or 90 off what feels best to you and we give them some income guidelines of typically people that are in this income bracket would choose the 30 off or the 60 off or whatever it might be which one feels right for you right now And then we,
as long as we have space in our 20%, sign them up and we don’t require any sort of income verification or anything along those lines. That has worked for us. What about your experience with offering sliding scale or reduced fee memberships? Is that something that you’ve done?
Yeah, I keep it a little simpler than you. I think you’re better with automations. And so you have that ability to do that. I offer up to a 50% discount. for families and sometimes I’m a little more flexible if they’re like adding their
third kid and they hardly ever come see me I might reduce it a little bit more for families who really need it I also see the children of some of my employees for free and I know that I know how much I pay them I know they’re not making a ton of
money and so I don’t pay them poorly I just don’t pay them enough that they have a ton of discretionary income And so I offer free care for some families and then also the discounted care for others. It’s very subjective. Like you, I don’t ask for pay stubs. I mean, can you do that? Yeah, absolutely.
You can decide what your criteria is for offering discounts. But I think it’s a nice way to serve the community. Probably 10% of my families are on a discounted rate only because… that’s just how the numbers have worked um especially moving into a new building
this past year higher overhead building out costs all that stuff i couldn’t do more than that but i also have found other ways of of serving that community i’ve mentioned before i see kids for car accidents and it involves a little bit of painful paperwork but those kids i’m seeing for the car accident but i’m also sort
of saying, hey, are you up to date on your vaccines? We have VFC vaccines. It’s an opportunity to catch them up. A lot of those families do not have insurance or are on Medicaid. And so I feel like that’s kind of a sideways way that I’m able to serve those
families and also answer questions that maybe their general pediatrician hasn’t answered. Just last week, I saw a kid and I started talking about just development. And this was a kid who was two and a half and wasn’t speaking yet. And I said, I’m going to put in a speech therapy referral for you because you’ve just fallen
through the cracks. Because I know what it’s like to work in those really busy, like community health centers. And that’s where they were going. So yeah, there are a lot of ways to kind of get creative. But this is one of them is definitely offering discounts.
Love it. Those are great ways to serve. What about the third thing you mentioned in the article was a community sponsorship fund. And I’ve always kind of thought about this idea and I’ve never pursued it, but tell me what your vision is here or what that could look like.
Yeah. I’ve seen this kind of discussed in some of the DPC docs, Facebook groups that people say, Hey, I really want to like raise some money from maybe some of my patients who make more money or people in the community who want to contribute. And you can create that kind of pool. It gets a little bit tricky.
One of the questions that always comes up is, can you count it as a write-off? Can you like basically account it for the person who’s contributing as a charitable contribution unfortunately it gets really tricky when you start exploring that because you would have to have a separate
non-profit and having created a non-profit before it’s a lot of paperwork and a lot of stuff to kind of keep track of from a financial perspective and so that would get pretty tricky honestly so i would say most people yeah most people when this
conversation comes up says what it’s not worth it you just have to tell people that this is not tax deductible but it’s going towards a good cause And I saw one DPC doctor who actually when people enroll, he has kind of three tiers and the top tier is like higher priced with the
understanding that they’re paying extra in order to help subsidize the membership for another person. Gotcha. The middle tier is sort of just like what it would regularly cost. And then the bottom tier is, hey, I’m in a hard financial situation.
I need a discount.
And so I thought that was a really clever way of doing it is right at enrollment, you offer patients those options and people who have a little extra money to contribute can do that.
I love that idea, especially because I think a lot of people when they’re signing up, that might be the chance where they’re like, yeah, we’ve had these privileges and we want to extend that and see the value of it. And I think then, I mean,
you can always talk about adding on intangibles as a thank you for making this extra contribution or something along those lines. There’s certainly different things that you could get into of ways that you’re not really like creating different echelons of care, but you are,
saying thank you for those that are able to do that since obviously getting into the whole tax deduction thing would be a huge can of worms that I would not have the, I mean me, I would not have the bandwidth and interest to set up a nonprofit, but I could say, Hey, I really appreciate that.
And here’s some other ways that we will, we want to show you our gratitude for the way that you have generously given above and beyond the the request and this is how it extends our mission and helps others uh-huh yeah
and i think that because of the way we practice i mean at least in my practice and in the practices of some of my dpc friends we tend to attract some really high income families in addition to many kind of middle class and other families, right?
So we really have kind of a mix of clientele, if you will. And so we kind of have that ability. We have great relationships that we foster with families who are in a financially more privileged situation. And once we have that relationship, can we send it out in our newsletter saying, hey,
we’re facing this situation in our community and we’re trying to find ways to help If you have extra to spare, would you consider contributing to this little community fund to help other children in the community access medical care? So there are a lot of ways of doing that.
And we have the relationships in our community to have a higher likelihood of being successful doing that.
Totally. And then what about I think the biggest one that we often don’t think like, well, what can we do is advocacy? And as professionals, we have more sway than we realize when it comes to talking with our elected officials because of our credentials and our respect and authority in the community.
And so I think that’s something that we often under under value in ourselves is that people will listen and you can get your voice out there in a way that the average Jane and Joe cannot because you’re able to share your experience and your expertise. So how can we as DPC pediatricians be part of that broader conversation?
Yeah, I think just getting involved in if you’re part of the American Academy of Pediatrics, you should have a state and local chapter. And so getting involved in that is an option. I’m part of mine, but I’m not too actively involved. What I actually did really get involved in when I moved to Utah several years ago
is the Utah Medical Association. And they have an annual what they call a House of Delegates where you get to be a voting member. And really just you kind of get you become more aware of like stuff going on on the legislative front in your state.
And so that’s really opened my eyes to all of the stuff going on behind the scenes and up on Capitol Hill, especially legislation that affects politics. doctors and patients and things like Medicaid. So yeah, it’s been really interesting to get involved and I’m actively involved in also their legislative committee. And so during legislative season in our state,
I sit in on meetings and get to kind of vote on the position that the Utah Medical Association will take when certain bills come up for consideration. So we really do have the ability to have a voice. Now, am I the only voice? Of course not,
but I get to be a little piece of that conversation and give my input when it comes to pediatrics and pediatric health in my community. What about you, Phil? Have you been involved in any organizations?
I think, yes, for me over the years, I haven’t been any since all of this one big, beautiful bill stuff came about and around, but in, in previous years, I’ve gone to our state legislature. So we’re unique in Nebraska in that we only have one body. We have the Unicameral rather than a house and a Senate.
We just have one.
So fun fact about Nebraska, the Unicameral. I’ve gone and testified on different things. And usually it’s come through our AMA chapter or Nebraska chapter of the American Medical Association. or the AAP. And those are the two ones where they’re looking for people to come and speak on behalf of specific things that are before them.
And they listen and they ask great questions and you are the expert. And it’s a great way to get in front of people that you wouldn’t otherwise see. And they ask really good questions and you can see the impact just last year. I was at the legislature talking about newborn screens because there was a push to
make it not mandatory. And in Nebraska and actually Nebraska state in that newborn screens are mandatory. And there was all sorts of the, the type of people that would come out and say, hands off my free hands off my baby’s blood, whatever you want. And we shouldn’t make it mandatory.
And when you, as the pediatrician show up and say, here’s A recent example where I had a child that had congenital hypothyroidism. They called me on a Saturday morning to say, hey, we think their newborn screen shows they have congenital hypothyroidism. By that evening, they were on Synthroid. If not for that,
it would have taken us months to figure out as the baby got floppier and stopped growing and lost all those neurons and stopped pooping. We would have eventually figured it out, but there would have been neurons that were lost that we never got back from that.
And when people hear that and realize that these aren’t just kind of like made up things, that the Internet is telling you about, that they’re real things that are happening to people in our community. They listen and those stories are really powerful. And so there’s plenty of opportunities for us to share and for people to listen.
So I think that is for me a really good way to get in front of and make a bigger impact because I can only do so much in my little corner of Lincoln, Nebraska here. But when you’re talking about the state or local people that have a say over policies in the community and for our whole state,
that that can be a really powerful way to advocate for kids that goes beyond the walls of our practice.
Definitely, yeah. And that’s interesting you mentioned that newborn screening issue because the same thing happened in Utah last year. And luckily, the Utah chapter of the AAP really stepped in and did exactly what you mentioned and really kind of brought reality to these legislators. And luckily, the law wasn’t changed.
So that’s an excellent example of how we can make a difference. As kind of a last note, I wanted to mention that the big, beautiful bill also included a small provision that in some ways helps DPC or at least patients who are trying to use HSA dollars to pay for DPC.
And so there was that little provision that says DPC is not health insurance, right? And just for legal reasons, that clarification is important. And then it also says that up to $150 per member can be paid using HSA dollars for DPC membership. I think there might be a $300 max. I can’t quite remember for families,
but at least it allows, it makes it written in law that it is okay to use HSA dollars for memberships. So just a little aside there.
Well, I think in the big picture, what this bill and just all the stuff in the news these days has illuminated is that things are changing. And we as pediatricians, especially those in direct primary care can be part of the solution in part because
we can work outside of all the guardrails that are put up by insurance and by Medicaid and all those sorts of things. We’re able to do things outside of that where we’re able to have more flexibility. And often we have the time to really dive deep, help those families,
and then advocate at the local state national level where our colleagues are just drowning in visits all day and don’t have the time to spend in the same way that we do. So I think that there’s plenty of opportunities for us in the DPC space to help.
And I would encourage you to check out Marina’s article on dpcpediatrician.com to learn more.
yeah all right well maybe someone out there will have even better ideas than we did here today please share them if you do because i think we all have to be part of these changes in society and part of creative solutions making sure that we can
still provide care to as many people as possible and thanks for listening everyone
before we go special announcement this fall marina and i are putting on the direct pediatric care virtual summit the very first one ever registration is free right now and so go to dpcpediatrician.com summit to save your spot it’s going to be three days virtual summit where people at each age
and stage of their pediatric practice can come they can learn if they’re curious they can connect, they can take those next steps towards starting their practice, growing their practice and beyond. And so if you are saying, I want more, I want to learn more, I want to go deeper, dpcpediatrician.com slash summit to save your spot.
Absolutely. We can’t wait to see you there. Don’t miss out on this opportunity. Wherever you are, whatever stage, whether you’re just contemplating or you have a mature practice, we are going to have content that’s relevant to you. All right, everyone. Thanks for listening. Until next time.
