Here's my take on all the affordability chatter in Washington: I haven't seen this level of interest in going after the underlying drivers of health care costs in the 11 years I've been covering the subject.

Why it matters: Lowering health care costs explicitly means clamping down on the business practices that make some people a lot of money.

• If either party is serious about any of this, it's declaring war on a sector that makes up nearly a fifth of the U.S. economy.

The big picture: Every major health care segment seems to be in trouble.

• Both parties are raging against "Big Insurance" and want to see profit-seeking behaviors checked.
• The pharmaceutical industry, which used to enjoy the full-throated backing of the GOP, has very few friends left who are willing to go to bat for it.
• And the protective halo that used to enshroud hospitals from political scrutiny has been pierced.

State of play: In recent weeks, an influential Democratic-aligned think tank has put out a health plan calling for premium regulation and hospital price caps, and a Republican-aligned one published a blog post attacking one of hospitals' arguments for more government funding.

• The Trump administration filed its second lawsuit accusing a hospital of anti-competitive contracting behavior.
• Senate Democrats have formed a working group to revamp private health insurance, House Democrats released a report on insurance denials and the administration slapped tariffs on drugmakers that haven't cut pricing deals.
• And let's not forget that Republicans' massive Medicaid overhaul last year included hundreds of billions in payment cuts to providers.

What they're saying: I ran my thesis by Chris Meekins, a senior health official in the first Trump administration and now an analyst for Raymond James.

• He agreed that there's been a shift.
• "Years of Americans' ennui around health care seems to have reached a depth that now politicians in both parties are seriously talking about costs and outcomes rather than being mainly Democratic talking points," he said.
• "This is a level we arguably have not seen since before creation of [Medicare] Part D," he added, noting that bipartisan policymaking would be much harder today than it was then.

Yes, but: Politicians have almost universally hated pharmacy benefit managers for years. They finally passed federal policy changes in February after the industry had had years to prepare.

• The pharmaceutical industry has survived two different administrations' efforts to lower drug prices, and analysts have largely dismissed the changes that were enacted as immaterial to companies' bottom lines.
• And while the Trump administration came in talking a big talk about insurers, it just backed off a Medicare Advantage payment policy that had health plans howling.

The bottom line: Health care costs have been going up forever. The question has always been whether they'd reach a breaking point — and politically speaking, we might be there.

• But we're still a ways off from serious attempts to rein in prices, and no future attempt is guaranteed to work.

Perhaps the most notable shift in tone is around hospitals.

• "We haven't really had a debate on hospital costs, and that's the main driver of health care costs," Center for American Progress senior fellow Topher Spiro told me this week when I interviewed him about the center's new health plan. "It's sort of been the elephant in the room and we need to confront it."
• "The main area that prices have increased in the entire American economy, not just health care, is hospital prices," Paragon Health Institute president Brian Blase told me.

The big picture: If policymakers truly want to address hospital costs, one of the fundamental problems they'll have to grapple with is the fact that so many markets are already heavily concentrated.

• In other words, competition isn't going to drive prices down in those markets.

Where it stands: Health care spending is highly variable across the country, and prices account for most of that, according to a new data analysis released yesterday by the Health Care Cost Institute.

• It bluntly declares that "hospital markets are not competitive," finding that a grand total of seven metro areas have hospital markets that are considered unconcentrated.
• Those markets are New York City, Los Angeles, Chicago, Riverside (California), Philadelphia, Miami, and Washington, D.C. So if you don't live in one of the largest cities in the country, you probably don't have a lot of choice.

Between the lines: Further complicating the problem is that in many markets, even metro areas, it doesn't make sense to have more than one or two hospitals.

• On the other hand, research has found that consolidation only accounts for part of hospitals' market power, and prices in competitive markets "aren't lower to the degree that some might imagine," American Enterprise Institute economist Ben Ippolito told me.
• "Going down this route of trying to regulate prices is very, very challenging, and so we want to enter those arrangements cautiously and only where we are really convinced we don't have another option," Ippolito said.
• "I worry that people are both too quick to give up hope for a decent amount of competition and they may overestimate just how much this specific issue is driving overall hospital prices," he added.

State of play: CAP's proposal jumps straight to limiting prices in consolidated hospital markets. But many policymakers, especially on the right, aren't there yet.

• "The systems are consolidated, I'm not sure how you reverse the consolidation," Blase told me. But, he said, the first step is "to address the government policies that have made the problem so bad and continue to make it worse."

Yes, but: Several states have already passed — or are trying to pass — laws that regulate hospital prices. They include red states, most notably Indiana, where the effort has recently attracted a lot of attention.

The other side: Chad Golder, general counsel at the American Hospital Association, said there are "many reasons why prices may vary" and it's "wrong to blame any single factor, especially any alleged concentration."

What we're watching: "We are moving ever closer to large portions of health care becoming treated like regulated utilities with government more broadly setting prices," Meekins told me.

Another interesting takeaway from the HCCI analysis: How expensive health care feels to you depends on where you live.

Why it matters: From a political standpoint, some of the states with this year's most competitive Senate races are also the states with the highest health care cost burden.

• I'm looking at you, Georgia, Alaska and Ohio.

Between the lines: In this case, "cost burden" is a measure that looks at health care spending in the context of an area's average income.

• That means West Virginia may not spend the most money or have the highest prices, but health care still feels most expensive to its residents relative to how much money they make.

The bottom line: Talking about health care affordability may hit a little closer to home in these states than in others.