EDITOR’S NOTE: Here’s an installment from Tillamook County’s State Representative Cyrus Javadi’s Substack blog, “A Point of Personal Privilege” Oregon legislator and local dentist. Representing District 32, I focus on practical policies and community well-being. This space offers insights on state issues, reflections on leadership, and stories from the Oregon coast, fostering thoughtful dialogue. Posted on Substack, 3/16/25
By Cyrus Javadi, State Representative District 32
Let’s be honest: watching the healthcare system implode can feel like binge-watching a dystopian drama you never intended to start. There is a maze of acronyms, from PBMs to 340B, and a series of negotiations so opaque that they make a magician’s top hat look transparent. It is amusing in a twisted way, at least until the day you see your favorite neighborhood pharmacy plastered with a “For Lease” sign, or you hear rumors that the local hospital you have relied on for years might be flirting with bankruptcy or a major merger. When it hits close to home, it becomes more than just another headline.
Most of us don’t pore over the Federal Register for weekend fun. Yet trouble has a way of showing up on Main Street, right where we live. The pharmacy you’ve visited for years is suddenly papered over with a “For Lease” sign, and the local hospital that once treated everything from ear infections to emergency surgeries quietly merges with a larger chain, slowly phasing out services. How did it get so complicated, and should you worry your neighborhood ER is next on the chopping block?
The Many Payers and Their Many Hurdles
A good starting point is to see how money flows—or doesn’t flow—in our bloated healthcare industry. Hospitals don’t rely on a single paycheck; they survive by piecing together multiple revenue streams. Medicare and Medicaid foot the bill for a lot of patient care, but their rates often lag behind the true cost of providing it. Picture your favorite sandwich shop selling a premium BLT for half the cost of the bacon alone.
Private insurers step into the ring next, theoretically paying more, but they also have an affinity for “negotiating” those rates down. Hospitals can’t exactly say no because turning away a major insurer means blocking a huge chunk of patients, which is about as financially suicidal as it sounds.
Finally, we have out-of-pocket payments from patients, though those have been shrinking as coverage has broadened—despite rising deductibles that complicate the picture.
Meanwhile, nurses, specialists, imaging machines, and every other cost keep climbing. It’s a perpetual game of whack-a-mole: fix one shortfall and three more pop up to whack you from behind.
Pharmacies on the Razor’s Edge
If hospitals are juggling a precarious budget, pharmacies often exist on an even thinner margin. They rely on the difference between what they pay wholesale for medications and what insurers or pharmacy benefit managers (PBMs) reimburse them, plus a tiny dispensing fee. Enter the PBMs, middlemen who set prescription reimbursement rates. Basically, saying “Buy that drug for $50, and we’ll give you $49 back—minus admin costs.” Keep that up, and your friendly neighborhood pharmacist loses a dollar per script. Multiply by a thousand prescriptions a week, and you can guess what happens next.
Sure, big chains like Walgreens and CVS can handle this a bit better because they negotiate bulk deals and lure you in with hair gel and Halloween candy aisles the size of football fields. But even these giants end up closing stores deemed unprofitable. Independent pharmacies have it worse. Without the bargaining power to get decent rates or the retail footprint to offset losses, they may try offering niche services—compounding, home delivery—but that’s usually a Band-Aid on a major wound. Sooner or later, you’ll show up to buy cough medicine and find a “CLOSED” sign taped to the door.
The 340B Maze
No discussion of pricing and reimbursements is complete without mentioning 340B, which might sound like the codename for a top-secret government agency but is actually a discount program from the early 1990s. The premise behind 340B is simple enough: if drug manufacturers benefit from broad Medicare and Medicaid coverage, they should extend a helping hand to hospitals and clinics serving low-income populations. In practice, it means these facilities can buy medications at bargain-basement prices, bill insurers at the usual rates, and then channel the extra revenue into essential services for underserved patients. In theory, it’s a neat solution to a thorny funding problem—a financial lifesaver for providers that can’t survive on Medicare and Medicaid reimbursements alone.
But what started as a modest safety net has grown into a sprawling lattice of contract pharmacies and eligibility rules, prompting Big Pharma to launch into an all-out Greek chorus of complaints. Their gripe isn’t just about money; it’s also about how dizzyingly complex the oversight has become.
In 340B’s simpler days, hospitals typically had their own in-house pharmacies, making it relatively straightforward to track which prescriptions qualified for the discount. Now, you’ve got hospitals partnering with a slew of retail pharmacies, and every single prescription has to be verified: does the patient meet the criteria, does the prescriber fall under the correct umbrella, is the facility’s status current?
Drug makers say that without more transparency—especially regarding where these savings ultimately go—there’s room for prescriptions to slip in when they shouldn’t, or for hospitals to pocket discounts that never reach the patients. So they’re pushing back with lawsuits, more audits, and fewer contract pharmacy allowances. Hospitals, in turn, argue that 340B is what helps them keep their ER lights on, especially given those persistent underpayments from Medicare and Medicaid.
The Manufacturer’s Perspective
From the viewpoint of drug companies, they’re getting squeezed from every angle like they’re the only rich uncle at a family reunion. They funnel billions into R&D, roll out a medication with a high price tag, and then face a parade of demands: PBMs want rebates, insurers negotiate discounts, and 340B forces additional markdowns for certain facilities.
Yes, it’s easy to roll your eyes when Big Pharma pleads hardship, especially if you’ve ever paid more for a brand-name drug than you do for your monthly rent. Still, their frustration centers on watching 340B expand beyond what they view as its original intent. They claim it now funnels a growing share of their inventory into discount land without clear proof those discounts always benefit low-income patients.
Patients at the Crossroads
Amid this backstage drama, the patient stands center stage, often blissfully unaware of the constant negotiations swirling around them. If you’re lucky enough to have comprehensive insurance, you might indirectly benefit from hidden discounts and rebates. But if you have a high-deductible plan or you’re stuck paying cash, you could be slammed with inflated list prices that bear no resemblance to the hush-hush rates carved out behind closed doors.
If your local pharmacy closes, you’ll end up driving an extra 10 miles just to get an antibiotic for a sinus infection. I know of one woman who had to drive 90 minutes to a pharmacy for medication in her final weeks of life because the local pharmacy was too backlogged to help her sooner. If your community hospital cuts back on labor and delivery services because the finances won’t line up, then expectant parents in town will have to travel to the next county—no small inconvenience, especially when someone’s about to give birth.
In theory, the system is supposed to funnel money from those with robust coverage to help cover those who don’t. In reality, it’s more like a Rube Goldberg machine. Each piece is designed to offset someone else’s shortfall, while everyone prays they can stay in the black. If one domino falls—a cut in Medicare rates, a new regulation curtailing 340B, or a PBM deciding to reimburse less—entire communities can face fewer healthcare options and longer wait times.
Hospital Mergers: The Lesser Evil or a Slippery Slope?
So, should you be sweating bullets about your local hospital’s survival? In many cases, yes—though you shouldn’t panic to the point of signing up for a do-it-yourself appendectomy class online. Plenty of hospitals remain open, but they operate on razor-thin margins. If Medicare and Medicaid keep underpaying, private insurers bully them on rates, and 340B revenue gets clogged by new restrictions, hospitals will look for a Plan B. Sometimes Plan B is merging with a larger hospital system to share overhead, boost negotiating power, and reduce duplication of services.
It might seem efficient from a business standpoint, but the resulting behemoth can wind up reducing competition, consolidating specialized services in one central hub, and leaving outlying areas with fewer options. If a major economic dip or another healthcare crisis hits, that bigger entity could still face a financial meltdown, taking multiple facilities down at once.
Looking for a Prescription to Fix This
“Why are pharmacies closing, and should we worry about hospitals?” boils down to a precarious web of reimbursements, negotiations, and programs that help some stakeholders while hurting others. Pharmacies disappear when margins dip below sustainability, and hospitals risk collapse when they can’t juggle underpayments, rising costs, and complicated middleman fees. Patients, ironically, keep this entire structure afloat yet are the ones who scramble when a local facility shuts down.
If you’re still hungry for answers, don’t expect them to be served on a silver platter. We can nudge for more transparency, for a clearer 340B focus, and for payers—government and private alike—to stop underpaying providers. But each fix meets resistance from some corner of the industry, leading to a messy push-pull that hardly anyone grasps in its entirety. Until a larger overhaul comes (or until healthcare is magically fixed by a benevolent genie), we’re stuck with a system where your next prescription or hospital stay might hinge on who’s willing to pay what behind closed doors.
Yes, it’s a frustrating game to watch, but it’s one that matters. The local pharmacy you rely on, the hospital that saves lives—these aren’t abstract businesses in a faraway city. They’re where real people get real care. So, the next time you see another boarded-up pharmacy window or hear about hospital department closures, don’t brush it off as just another sign of the times. Instead, remember it’s all connected, and that connection might eventually decide how far you drive when your kid has an ear infection or whether your local ER remains open to treat that next heart attack.
If that doesn’t get your heart racing, I don’t know what will.
