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Table of Contents
The mess in one paragraph
Define patient like an adult
Contract pharmacies need a leash, not a cage
Rebates, but with guardrails
Duplicate discounts and the Medicaid data problem
Make the discount show up somewhere visible
Give HRSA actual teeth and an actual budget
What Congress has to do vs what HRSA can do
Who wins, who loses, who pretends to lose
Abstract
340B is a roughly 124 billion dollar a year program run by a 1992 statute, a couple dozen employees, and a lot of vibes
Most of the fighting (contract pharmacy restrictions, rebate pilots, state laws, duplicate discounts) traces back to four or five undefined terms
This piece lays out the specific reg changes that would fix most of it: a real patient definition, a contract pharmacy registration and data standard, a rebate model with hard turnaround and audit rights, a claims-level duplicate discount clearinghouse, mandatory savings reporting, and enforcement authority HRSA can use without getting sued into a ditch
Splits each fix into what HRSA can do alone vs what needs Congress
Ends with the honest scorecard of who gains and who loses, and why the loudest opponents of reform are not always the ones with the most to lose
