Providers generally support the Internal Revenue Service’s plan to make payments for direct primary-care arrangements tax-deductible but oppose the agency’s effort to promote healthcare sharing ministries by treating them like health insurance.

The IRS would consider payments for direct primary-care contracts and healthcare sharing ministry memberships “qualified medical expenses” under the proposed rule, making them tax-deductible in many instances. Employers could also pay their employee’s direct primary-care or healthcare sharing ministry expenses through health reimbursement arrangements.

Providers say the proposal could make it easier for people to afford more access to primary-care services. But they think the agency should use its power to allow health savings accounts—HSAs—to pay for direct primary-care arrangements. Not allowing them to do it is “the key regulatory barrier that prevents individuals with HSAs from participating in a (direct primary-care) arrangement,” the American Medical Association said in a letter to the IRS.

The tax code only allows people to participate in an HSA if they have a high-deductible health plan. Individuals can use their HSA to pay for added, specific coverage like dental or vision. But they can’t use it to buy coverage other than a high-deductible plan or to cover any benefit paid for by such a plan.

Under the current and proposed rules, people can’t use an HSA to pay for direct primary care because high-deductible plans cover primary-care services.

Providers say the IRS should allow people to use HSAs to pay direct primary-care fees since patients enrolled in direct primary-care practices need to carry health coverage for prescription drugs, emergency care, hospitalizations and other services that aren’t primary care.

Clinicians disagree over whether the IRS should expand the definition of a direct primary-care arrangement to include clinicians besides physicians, such as nurse practitioners or physician assistants. Physician groups argue the agency shouldn’t change its definition of direct primary care because several state and federal laws already address it.

“If state medical licensure or government payers (e.g., CMS) permit non-physician practitioners to provide primary-care services we see no reason why the IRS needs to limit or change these conditions strictly for the purposes of tax treatment of (direct primary-care) agreements,” said the Direct Primary Care Coalition, a trade group representing primary-care physicians and other direct primary-care supporters.

The AMA said the IRS should add obstetricians and gynecologists to its definition of direct primary care and exclude nonphysicians.

But the American Association of Nurse Practitioners argued the IRS should include nonphysicians like nurse practitioners in its direct primary-care definition because it’s consistent with President Donald Trump’s October executive order on Medicare, which called for regulators to address “disparities in reimbursement between physicians and nurse practitioners within the Medicare program.”

The Trump administration has made expanding clinicians’ scopes of practice and allowing them to practice at the top of their license a significant part of its healthcare agenda, including such changes in its COVID-19 relief measures and new Medicare payment rules. The vast majority of research shows that nurse practitioners, physician assistants and other nonphysician practitioners deliver high-quality care to patients. Physicians and other clinicians are in a turf war over what kinds of care different clinicians can provide.

Many policymakers think that allowing nonphysicians to deliver more care could improve access and rein in healthcare spending.

Providers said they oppose the administration’s plan to treat healthcare sharing ministries equal to health insurance and, in turn, make them tax-deductible. Unlike conventional health plans, state and federal insurance regulations don’t govern the ministries. Healthcare sharing ministries also don’t have to cover preexisting conditions or even pay for healthcare services.

“Patients seeking affordable coverage following job losses and other life events, end up with a healthcare sharing ministry plan and are unaware that the plans will not be there when they need them most. The proposed rule will only exacerbate this misconception by deeming such plans medical insurance in one instance while continuing to allow them to sell products with no consumer protections,” the American Hospital Association said in its comments on the rule.

The Trump administration has looked to expand the use of healthcare sharing ministries as a more affordable way for consumers to pay for healthcare expenses. But many experts worry the arrangements could weaken the individual market by attracting young, healthy consumers with low prices.