The 340B Rebate Idea Is Back, and Due Process Is Still on the Wait List

I spent part of last night in the familiar civic perfume: old paper, stale coffee, and that courthouse-air scent of people arguing about money while insisting it is about principles. A docket is never just a docket. It is a weather report for the rest of us.

What HRSA just did

HRSA (inside HHS) has put the 340B rebate model back on the table by publishing a Request for Information in the Federal Register on February 17, 2026. The comment deadline is March 19, 2026.

The agency is asking for input on the operational guts of a potential 340B rebate model pilot: costs, cash-flow impacts, reporting, data collection, and even how rebates might be denied. Translated into plain English: this sketches a system where covered entities could pay full price up front and later get the 340B price difference back as a rebate.

Why this is happening (again)

HRSA also notes that the U.S. District Court for the District of Maine, on February 10, 2026, vacated and remanded earlier 340B Rebate Model Pilot Program application notices and related manufacturer approvals. And in a February 5 court filing described by the American Hospital Association, HHS said it would scrap the existing rebate pilot and consider restarting the administrative process.

So yes, the paperwork is back. The question is what it buys besides more paperwork.

The tradeoff: transparency for whom, leverage over whom?

Manufacturers and allies frame a rebate model as a cleanup tool: more transparency, fewer duplicate discounts. Safety-net providers answer with blunt arithmetic: if you replace an immediate discount with a delayed rebate, you turn a statutory benefit into a cash-flow bet, with rural and thin-margin facilities cast as involuntary lenders.

This matters because 340B is not small beer. Axios reports the program covers more than $81 billion in annual drug purchases. When the number is that big, every tweak grows its own industry, and every industry hires a choir.

The Paine test and the Orwell check

The Paine test: does this expand liberty in the health system, meaning more predictable access and rules, or does it concentrate power by adding new levers and new compliance costs?

The Orwell check: notice how “discount” becomes “rebate.” A discount is legible and immediate. A rebate is conditional and slow, with homework attached. HRSA is explicitly asking about staffing, systems, reporting, and data collection. When you need elaborate infrastructure to receive what the statute already promises, you are building a compliance regime, not just “improving transparency.”

Guardrails, before the next court date

The American Hospital Association and other groups, in a February 19, 2026 letter to HRSA, asked to extend the comment period to April 20, 2026, arguing the current window is too short to answer dozens of detailed questions with facts and evidence.

If this idea is going to survive, it needs sunlight and guardrails: a serious comment window, published assumptions, and a uniform, auditable, fast rebate timeline with consequences for late payment. If new data flows are required, HRSA should be explicit about what is required, what is prohibited, and how patient privacy is protected in practice.

And, better yet, Congress should clarify the rules for 340B in statute instead of outsourcing policy to an accounting trick. So here is the question: do you want 340B to be a clean discount that supports the safety net, or a rebate maze where the strongest balance sheets win?