Prescription drug list prices in the United States continually rank among the highest in the world. The high cost of prescription drugs became a major topic of discussion in the 21st century, leading up to the U.S. health care reform debate of 2009, and received renewed attention in 2015. One major reason for high prescription drug prices in the United States relative to other countries is the inability of government-granted monopolies in the U.S. health care sector to use their bargaining power to negotiate lower prices and that the US payer ends up subsidizing the world's R&D spending on drugs.