I logged into the Zoom not knowing how long the meeting would run. Two staffers appeared on my screen, one in Los Angeles and one in Sacramento, representing senators who will never meet most of the patients I see every day. The call lasted thirty minutes. I came prepared for far more. The IRS guidance sat open on my desktop. Bernie Sanders’ HELP Minority Report from the day before was annotated next to the GOP “Health Care Freedom for Patients Act,” both showing premiums doubling and families being pushed into bronze and catastrophic plans. Screenshots of lab bills, denial letters, and frantic messages from patients choosing between their mortgage and their health insurance were ready to share. The full structure of the coverage collapse sat in front of me in tabs, notes, and examples.
The conversation opened with pleasantries and shifted immediately into policy. Policy takes a long time. Legislative change takes a long time. Federal and state authority work differently. The IRS is federal. Covered California is state. Every agency has a separate lane. I listened to each distinction and recognized something I’ve lived in medicine: turfing. Primary care hands the patient off to a specialist. The specialist sends them straight back to primary care. Pain management pushes the case to psychiatry. Psychiatry redirects it right back. Everyone claims responsibility ends at the edge of their role, and meanwhile the patient deteriorates in the gap. This meeting carried that same pattern.
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At one point I asked directly, “Where are the physicians who see this harm?” They replied that they work with physician groups. They replied that they consult organizations. They replied that they talk to various teams. None of that addressed the actual question. Physicians practicing direct primary care are not represented by those groups. Doctors who watch patients pay cash for denied labs, who manage the fallout from unusable insurance, who understand why DPC exists at all, were not part of the process shaping the policies I was being told to accept. Even many traditional clinicians do not understand why their peers are leaving the insurance model altogether.
The gap between what I prepared and what I was allowed to say widened with every minute. I never reached the part where the title “HELP Minority Report” becomes a political landmine that invites misinterpretation before anyone reads the data. I never had space to explain how that report, despite its branding, supports the concerns I brought. I never connected the IRS fee cap on direct primary care to the real consequences for California patients who will be penalized for choosing actual access over theoretical coverage.
The entire experience felt like a root canal combined with doing my taxes. Policy work grinds in a way that medicine never did. The rules are written in nonhuman language. None of it reflects the urgency of clinical care. I never imagined a career that required reading Treasury notices after clinic or parsing Senate staff drafts between patient messages. Yet the only alternative is looking away while people are harmed.
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Stories from my patients kept echoing in the back of my mind. They tell me their premiums match their mortgage. They ask whether they should keep the house or the health insurance. They try to calculate which risk is more survivable. They understand that losing either one collapses the other. Maslow’s hierarchy is not a diagram to them; it is a daily triage between shelter, safety, and health.
The staffers looked worn down. Their faces had the flat, tired expression I recognize from residents finishing a brutal call cycle. Their mental capacity was already stretched before I shared anything. I didn’t sense malice. I sensed depletion. Government burnout mirrors physician burnout but carries a different consequence. When doctors burn out, patients lose their clinicians. When policy staff burn out, patients lose the structure that protects them.
What they also didn’t see is how many physicians are quietly preparing to walk away. Canada is actively recruiting American doctors. New Zealand is doing the same. Both offer stable workloads, transparent systems, and the ability to practice medicine without constant combat against denials. Direct primary care physicians have already stepped outside the old framework and built a parallel network that functions because it has to. Every new penalty or regulation pushes more clinicians to look up licensure steps abroad.
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My time as a civil surgeon for the Department of Homeland Security shaped how I see this. Immigrants who trained as physicians and nurses often asked how to recreate direct primary care in the countries they came from. They recognized immediately that this model makes sense because it strips away the administrative chaos and allows medicine to be medicine. Their insight stays with me whenever a policy meeting dismisses timelines with words like “benchmarks” and “future review.”
The smallness of the meeting weighed against the scale of the crisis. Coverage is collapsing. Premiums are rising beyond reach. Deductibles are impossible to meet. Denials have become the default. MEC penalties hit people who choose DPC because it is the only functioning care they can access. Families with chronic illness, families living paycheck to paycheck, and families already stretched by housing costs are being asked to finance insurance structures that fail them at the point of need. All of that sat behind my monitor while the clock ran out and they wrapped the meeting at the thirty-minute mark.
I left feeling unheard and unseen, which matched the stories my patients tell me when they try to navigate the same system. This experience showed me exactly what happens when medicine meets policy: the urgency of care crashes into the pace of bureaucracy, and the patient falls through the gap. I did send a follow-up email with the materials I could not present. I know they will need that information when this debate resurfaces, because the consequences will reach their districts whether or not they prepare for them. My patients cannot step away from this. I cannot step away either. If the system keeps circling around definitions while Californians lose access, the coverage collapse will evolve into a full care collapse. The meeting ended after thirty minutes; the consequences will not.
The smallness of the meeting weighed against the scale of the crisis. Coverage is collapsing. Premiums are rising beyond reach. Deductibles are impossible to meet. Denials have become the default.
