> And why aren't there startups out there coming to compete for this gigantic money pool by offering a mere 400% markup? Regulation. If you wanted to start a s

> And why aren't there startups out there coming to compete for this gigantic money pool by offering a mere 400% markup? Regulation. If you wanted to start a service that drives elderly patients to get their medicine, in some justictions you need the permission of the local ambulance company to make sure you don't cut into their profits. This process is called a certificate of need[0] and if you dont have one, you can't operate. It's like this with virtually everything medical related. If you try to compete they have ways to shut you down or stop you from starting all together. [0]https://www.usnews.com/news/best-states/articles/2021-07-09/on-the-heels-of-the-pandemic-states-should-get-rid-of-certificate-of-need-laws https://www.usnews.com/news/best-states/articles/2021-07-09/... See also: Controlling the supply of doctors by limiting residency slots (https://www.aamc.org/news-insights/medical-school-enrollments-grow-residency-slots-haven-t-kept-pace https://www.aamc.org/news-insights/medical-school-enrollment...) Banning the reimportation of drugs produced in the US back from Canada at lower prices. Keeping older, safe, and well known drugs behind the counter (albuterol is a good example) to drive office visits and keep pharmacy revenues up. In other countries you can just buy many common drugs like that over the counter, cheaply.