Careful analysis of the seemingly intractable problem of rising medical costs can typically be reduced to three things: 1) who pays? (the accustomed answer generally being “someone else”); 2) the creeping role of the federal government in making that determination; and 3) the parasitic, and growing, impact of litigation. The back-and-forth over the 340B drug program buttons tight around each of these.

The basic problem of the gestating cost of healthcare is a classic economic one: There is too much demand for the available supply. Some of that demand is largely inelastic — if your heart or lungs malfunction or a piece of you is suddenly separated from its normal place on your body, you require medical care. But a considerable amount of the medical demand is more arbitrary, encouraged by the fact that in most cases someone else is picking up all or part of the tab — one’s insurance, one’s employer, or one’s neighbor via the altruistic machinations of Uncle Sam. Indeed, when we talk about “free” healthcare, what we mean is healthcare someone else pays for via taxation. In any case, the cost burden is falling on someone, and, invariably, that someone will seek out ways to shift that burden onto someone else.