Check out John Shutt's thesis on Kernel: https://web.cs.wpi.edu/~jshutt/kernel.html. He takes your observation that quasiquotation is pointless to the limit, dropping it entirely and constructing his macros out of cons and friends.
Thanks for the pointer. He has an entire chapter on hygiene... And then there is this:
"There is no need to provide quotation here because, having failed to enforce the prohibition against embedding combiners in a macro expansion, we don’t need to embed their unevaluated names in the expansion."
It's nice that his primitive $vau grabs the current lexenv, as this enables another kind of macro-like behavior I've thought might be useful: taking subexpressions, fully macroexpanding them, and doing something with the result (e.g. determining whether a variable is ever used, and omitting a computation if not). I don't know how that would mesh with the interpreter's semantics, though...
I'll probably have to read and brood on this further.