Evaluated alongside the administration's actions so far, the early proposal hints at Trump's priorities. 

This article was published on Wednesday, May 21, 2025 in KFF Health News.

By Aneri Pattani

Since President Donald Trump released his 2026 budget blueprint in early May, calling for $163 billion in federal spending cuts, much of the attention has focused on his slashing of foreign aid and boosting of border security. But the proposal also holds important clues — amid some mixed messages — about the administration's approach to two pressing public health issues: mental health and addiction.

There are about 80,000 overdose deaths in the United States each year, recent data shows, and nearly 50,000 deaths by suicide. Trump's proposal includes heavy cuts, totaling more than $22.6 billion, to three federal agencies that address these issues and suggests eliminating programs aimed at suicide and overdose prevention. The administration says this will streamline its efforts, but advocates, researchers, and public health practitioners worry this could make the death toll even worse.

Of course, a proposal is far from a final budget.

And this isn't even a full budget proposal. It's what people on Capitol Hill call a "skinny budget." It covers only discretionary spending that Congress authorizes each year, not larger entitlement programs like Medicare, Medicaid, and Social Security. Those big-ticket items and many other details will be addressed in the administration's full budget, expected in the coming months.

Still, evaluated alongside the administration's actions so far — including slashing the federal health workforce and disupting grants to addiction recovery programs — the early proposal hints at Trump's priorities.

"You don't have it in enough detail to be able to really make assessments" about specific policies, said Rodney Whitlock, a vice president at the McDermott+ consulting firm and a longtime Republican Senate staffer. But "even in a skinny budget, you have to take it seriously and think that, 'Oh yeah, they're going to try to accomplish this.'"

About two weeks before Trump released his skinny budget, a preliminary budget document for the Department of Health and Human Services was leaked, showing deep funding cuts and lists of programs slated for elimination.

Discrepancies between those two documents — the official, skinny budget and the more detailed leaked one — have muddled the budget process even more than usual.

Here are three things that millions of Americans experiencing mental illness or addiction, and their loved ones, should watch as the process continues.

1. There is considerable confusion about the future of suicide prevention programs, including the nation's mental health crisis hotline, 988.

Trump plans to propose spending $520 million on the 988 system next year — the same amount as in the current fiscal year, said Rachel Cauley, a spokesperson for the White House Office of Management and Budget. She told KFF Health News that the president's budget will include an additional $95 million for other suicide prevention programs.

But that's far from clear when looking through the only official budget document released so far.

Trump's skinny proposal calls for more than $1 billion in cuts to the Substance Abuse and Mental Health Services Administration, the government's lead agency on all things related to mental health and addiction. The proposal says much of that comes from "eliminating inefficient funding" for SAMHSA's Programs of Regional and National Significance.

This bucket of spending includes a variety of grant programs, in areas including children's mental health and homelessness prevention. Budget documents from the current fiscal year show some of the costliest programs under this title focus on suicide prevention, including 988 grants to ensure state and regional call centers have the capacity to handle the millions of calls and texts the crisis line receives, Garrett Lee Smith grants focused on preventing youth suicide, and Zero Suicide grants that help health systems develop comprehensive suicide screening and response protocols.

Many people consider these programs vital given the country's ongoing suicide crisis. From 2000 to 2018, the national suicide rate increased 35%. Although there was a slight dip the following two years, the rate returned to its peak in 2022.

The 988 system, since launching in 2022 under the Biden administration, has fielded more than 9.8 million calls and 2.5 million texts.

"Cutting this funding is going to be disastrous," said Paul Nestadt, a psychiatrist and an associate professor at Johns Hopkins University. "A lot of suicide prevention does take place at the state or even local level, but it's funded by federal programs."

The skinny budget proposal says, "These programs either duplicate other Federal spending or are too small to have a national impact."

Cauley did not respond to questions about where she got the 988 and suicide prevention funding numbers she cited or why they differ from what's noted in the skinny budget.

Although it's fairly common to see discrepancies among an administration's various budget documents, attention to these documents — and concerns about differences — are heightened this year amid the Trump team's efforts to radically downsize the government and federal spending.

"It's very confusing," said Laurel Stine, chief advocacy and policy officer with the American Foundation for Suicide Prevention. "We want to ensure that the 988 lifeline is safeguarded," but the only officially released budget document "doesn't speak to it at all."

Another point of confusion: The skinny budget suggests that states can accomplish the work supported by the eliminated funding through separate block grants they receive from the federal government to address mental health and addiction.

However, those grants are specifically aimed at caring for people with serious mental illness and cannot be spent on suicide prevention for the general public.

2. The administration wants to cut certain tools used for preventing drug overdoses.

In the skinny budget, the Trump administration says it is "committed to combatting the scourge of deadly drugs that have ravaged American communities."

It goes on to propose eliminating the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control, which has overseen a lot of overdose prevention work, and consolidating the infectious disease and opioids program with three other programs, effectively reducing its budget and capacity.

Some advocates, clinicians, and researchers worry such actions could reverse the recent progress made on overdose deaths.

"President Trump says that he wants to protect Americans from fentanyl," said Hanna Sharif-Kazemi, who works on federal affairs for the Drug Policy Alliance, an advocacy organization for people who use drugs. "But the plan that he has outlined in his budget proposal really doesn't match those words."

The proposal refers to "harm reduction" efforts, including providing sterile syringes to people using drugs, as "dangerous activities" and suggests federal funds should not support them.

But syringe service programs are among the most studied interventions and are proven to reduce the transmission of infectious diseases, such as HIV and hepatitis, without increasing crime or drug use.

They also "do so much more than just give syringes," Sharif-Kazemi said, adding that they typically distribute naloxone, which can reverse opioid overdoses, and connect people to resources for food, housing, and treatment, which help keep them alive.

Without these programs, infectious diseases are more likely to spread and affect the broader community, said Nestadt, the Johns Hopkins professor. "Eliminating those programs is going to have terrible effects on the population of the United States, regardless of whether they're using opiates or not."

3. Research cuts aimed at 'DEI' could worsen disparities in suicide and overdose rates.

The Trump proposal takes an axe to the National Institutes of Health, wiping out nearly $18 billion of the research agency's budget and eliminating several centers within it, including the National Institute on Minority and Health Disparities.

These actions align with Trump's ongoing attacks on "diversity, equity, and inclusion" programs, which he calls "woke" ideology.

Researchers say the proposed cuts, if enacted, could hamper efforts to address racial disparities in mental health and addiction that have become increasingly prominent.

Although national overdose deaths dropped last year, rates have increased in many Black and Native American communities.

Suicide rates have been rising faster for Black Americans than for their white counterparts. Early in the covid-19 pandemic, when suicide rates decreased for white Americans, they trended in the opposite direction for Black Americans and other communities of color.

"It might seem to the layperson that suicide is suicide, overdose is overdose," Nestadt said. But the data shows that trends are different for different groups. That means the factors that drive them to suicide — and the interventions that could save their lives — may be different.

"If I want to reach people with suicidal thoughts that are a highly educated, affluent population that has access to health care, I'm going to go to primary care doctors and pediatricians" to implement interventions, Nestadt said. But when trying to reach urban Black teens who have limited access to health care, "maybe it's a church" or barbershop, he said.

Nestadt is currently working on a CDC-funded study in which he interviews the family and friends of Black youths who died by suicide to understand what led to that point and how it could be prevented. He worries his funding could be cut any day.

What happens next?

Nothing in any Trump budget proposal is final. Lawmakers hold the power to determine federal spending.

Although some advocates worry that congressional Republicans will simply accede to Trump's demands, Whitlock, the McDermott+ consultant, said, "Congress is always going to want to express its will, and this will be no different."

Susan Collins, the Republican chair of the Senate Appropriations Committee, which oversees the budget, has stated that she has "serious objections" to some of the proposed cuts.

And when Health and Human Services Secretary Robert F. Kennedy Jr. appeared before House and Senate committees on May 14, some lawmakers pushed back on the administration's plans. Rep. Madeleine Dean (D-Pa.) held up a packet of naloxone and said the government should amplify what works to decrease overdose deaths instead of shuttering SAMHSA.

"Help us save more lives," she said. "Don't shift it and shaft it."

Aneri Pattani: apattani@kff.org, @aneripattani

Under a new executive order, prescription drug prices will be reduced 'almost immediately.' — President Donald Trump, in a May 11 post on Truth Social.

This article was published on Tuesday, May 20, 2025 in KFF Health News.

By Louis Jacobson, PolitiFact

President Donald Trump expressed high hopes for an executive order to reduce drug prices.

On May 11, the day before he held a White House event to sign the executive order, Trump posted on Truth Social, "Prescription Drug and Pharmaceutical prices will be REDUCED, almost immediately, by 30% to 80%."

However, the executive order's text, unveiled May 12, undercut the president's description of how soon consumers could experience this potential boon.

The idea of the executive order, he said, was to lower high prescription drug costs in the U.S. to levels more typical in other countries.

"We're going to equalize," Trump said at the order signing. "We're all going to pay the same. We're going to pay what Europe's going to pay."

Experts said Trump's action could lower the cost of prescription drugs, perhaps by the 30% to 80% Trump said, but they cautioned that the order's required procedural steps would make it far from an immediate fix.

The executive order says that within 30 days, administration officials must determine and communicate to drugmakers "most-favored-nation price targets," to push the companies to "bring prices for American patients in line with comparably developed nations."

After an unspecified period of time, the administration will gauge whether "significant progress" toward lower pricing has been achieved. If not, the order requires the secretary of Health and Human Services to "propose a rulemaking plan to impose most-favored-nation pricing," which could take months or years to take effect.

"Executive orders are wish lists," said Joseph Antos, a senior fellow emeritus in health care policy at the conservative American Enterprise Institute. The order "hopes that manufacturers will unilaterally lower U.S. prices. The legal authority to intervene in the market is unclear if this implausible scenario doesn't happen."

When contacted for comment, the White House did not provide evidence that the executive order would provide immediate results.

Why Do Americans Pay More for Prescriptions?

There is wide agreement that drug prices are unusually high in the U.S. The prices Americans pay for pharmaceuticals are nearly three times the average among a group of other industrialized countries in the Organization for Economic Cooperation and Development.

A study by the Rand Corp., a nonpartisan research organization, found that, across all drugs, U.S. prices were 2.78 times as high as the average prices across 33 OECD countries. The gap was even wider for brand-name drugs, with U.S. prices averaging 4.22 times as much.

The U.S. has lower prices than comparable nations for unbranded, generic drugs, which account for about 90% of filled prescriptions in the U.S. But generics account for only a fifth of U.S. prescription drug spending.

Experts cite several reasons for this pricing discrepancy.

One is that the U.S. has more limited price negotiation with drug manufacturers than other countries do. Often, if another country fails to find the extra cost of a new drug is justified by improved results, it'll reject the drug application. Some countries also set price controls.

Another factor is patent exclusivity. Over the years, U.S. pharmaceutical companies have used strong legal protections to amass patents that can keep generic competitors from the marketplace.

Drug companies have also argued that high prices help pay for research and development of new and improved pharmaceuticals. When Trump released the executive order, Stephen J. Ubl, president and CEO of the drug industry group Pharmaceutical Research and Manufacturers of America, said in a statement, "It would mean less treatments and cures and would jeopardize the hundreds of billions our member companies are planning to invest in America." (In Trump's May 13 interview with Fox News' Sean Hannity, Trump offered a different picture of what drug company officials have told him; he said they agreed "it's time" to lower U.S. prices.)

Recent studies have cast doubt on the idea that high prices pay for research and development. A 2023 study found that from 1999 to 2018, the world's 15 largest biopharmaceutical companies spent more on selling and general administrative activities, which include marketing, than on research and development. The study also said most new medicines developed during this period offered little to no clinical benefit over existing treatments.

The long-standing reality of high U.S. drug prices has driven Democratic and Republican efforts to bring them down. Then-President Joe Biden signed legislation to require Medicare, the federal health care program that covers Americans over 65, to negotiate prices with the makers of some popular, high-cost medicines. And Sen. Bernie Sanders (I-Vt.) has made lowering drug prices a cornerstone issue during his political career.

During his first term, Trump sought to lower prices for certain drugs under Medicare, but the courts blocked the move on procedural grounds.

Trump's drug-price push could attract bipartisan support, experts said.

Jonathan Cohn, who has worked for several left-of-center media outlets and wrote two books on health care policy, offered measured praise for Trump's executive order in The Bulwark, a publication generally critical of Trump, calling it "a serious policy initiative, one that credible people think could bring some relief on drug prices."

Andrew Mulcahy, a Rand Corp. senior health economist, said one part of Trump's statement — the possibility of a 30% to 80% price reduction — is plausible.

"Of course, the devil's in the policy design and implementation details," Mulcahy said. "But at first blush, a savings of roughly two-thirds on what we spend now for drugs seems in line" with what Rand's research has shown.

What Would Trump's Executive Order Do?

Referring to high U.S. drug prices, Trump told Hannity that "I ended it" by issuing the executive order. But that's not how the order is structured.

The executive order makes plain that any actions will not happen quickly.

"That 'almost' in 'almost immediately' is doing a lot of work," Mulcahy said, referring to Trump's statement.

The executive order also could face court challenges, just as Trump's first-term executive order did.

"It seems unlikely that the federal government can set prices for drugs outside of the Medicare program," Antos said. If Trump wants reduced prices to benefit all U.S. consumers, experts said, Congress will likely have to pass new legislation. While executive orders direct federal agencies what to do, requiring action from privately owned companies likely would require legislation passed by Congress, experts said.

If Congress gets involved, that will not only tack on extra time, but it also could draw opposition from the Republican majority in one or both chambers. Historically, Antos said, "federal price controls are anathema for many Republicans in Congress."

Our Ruling

Trump said that, because of his new executive order, prescription drug prices would be reduced "almost immediately."

Experts said that if the goals of the executive order are achieved, price reductions would not happen "almost immediately."

The order sets out a 30-day period to develop pricing targets for drugmakers, followed by an unspecified amount of time to see if companies achieve the targets. If they don't, a formal rulemaking process would begin, requiring months or even years. And if Trump intends to lower prices for all consumers, not only those who have federal coverage such as Medicare, Congress will likely have to pass a law to do it.

Trump gives the impression that Americans will shortly see steep decreases in what they pay for prescription drugs. But even if the executive order acts as intended — which would require a lot to go right — it could take months or years.

The statement contains an element of truth but ignores evidence that would give a different impression. We rate it Mostly False.

More than a hundred rural hospitals have stopped delivering babies since 2021 owing to shortages of staff and money.

This article was published on Monday, May 19, 2025 in KFF Health News.

By Arielle Zionts

WINNER, S.D. — Sophie Hofeldt planned to receive prenatal care and give birth at her local hospital, 10 minutes from her house. Instead, she's driving more than three hours round trip for her appointments.

The hospital, Winner Regional Health, recently joined the increasing number of rural hospitals shuttering their birthing units.

"It's going to be a lot more of a stress and a hassle for women to get the healthcare that they need because they have to go so much further," said Hofeldt, who has a June 10 due date for her first child.

Hofeldt said longer drives mean spending more on gas — and a higher risk of not making it to the hospital in time. "My main concern is having to give birth in a car," she said.

More than a hundred rural hospitals have stopped delivering babies since 2021, according to the Center for Healthcare Quality and Payment Reform, a nonprofit organization. Such closures are often blamed on shortages of staff and money.

About 58% of South Dakota counties have no birthing facilities, the second-highest rate among states, after North Dakota, according to March of Dimes. And the South Dakota health department says pregnant women and infants in the state, especially those who are Black or Native American, experience high rates of complications and death.

Winner Regional Health serves rural communities, including parts of the Rosebud Sioux Indian Reservation, in South Dakota and Nebraska. It delivered 107 babies last year, down from 158 in 2021, said CEO Brian Williams.

The nearest birthing hospitals are in rural towns an hour or more from Winner. But several women said driving to those facilities would take them through areas without reliable cellphone service, which could be a problem if they have an emergency along the way.

KFF Health News spoke with five patients from the Winner area who planned to deliver at Avera St. Mary's Hospital in Pierre, about 90 miles from Winner, or at one of the large medical centers in Sioux Falls, 170 miles away.

Hofeldt and her boyfriend drive every three weeks to her prenatal appointments at the Pierre hospital, which serves the small capital city and vast surrounding rural area. She'll have to make weekly trips closer to her due date. Neither of their jobs provides paid time off for such appointments.

"When you have to go to Pierre, you have to take almost the whole day off," said Hofeldt, who was born at the Winner hospital.

That means forfeiting pay while spending extra money on travel. Not everyone has gas money, let alone access to a car, and bus services are scarce in rural America. Some women also need to pay for child care during their appointments. And when the baby comes, family members may need to pay for a hotel.

Amy Lueking, Hofeldt's doctor in Pierre, said when patients can't overcome these barriers, obstetricians can give them home monitoring devices and offer phone- or video-based care. Patients can also receive prenatal care at a local hospital or clinic before connecting with a doctor at a birthing hospital, Lueking said.

However, some rural areas don't have access to telehealth. And some patients, such as Hofeldt, don't want to split up their care, form relationships with two doctors, and deal with logistics like transferring medical records.

During a recent appointment, Lueking glided an ultrasound device over Hofeldt's uterus. The "woosh-woosh" rhythm of the fetal heartbeat thumped over the monitor.

"I think it's the best sound in the whole wide world," Lueking said.

Hofeldt told Lueking she wanted her first delivery to be "as natural as possible."

But ensuring a birth goes according to plan can be difficult for rural patients. To guarantee they make it to the hospital on time, some schedule an induction, in which doctors use medicine or procedures to stimulate labor.

Katie Larson lives on a ranch near Winner in the town of Hamill, population 14. She had hoped to avoid having her labor induced.

Larson wanted to wait until her contractions began naturally, then drive to Avera St. Mary's in Pierre. But she scheduled an induction in case she didn't go into labor by April 13, her due date.

Larson ended up having to reschedule for April 8 to avoid a conflict with an important cattle sale she and her husband were preparing for.

"People are going to be either forced to pick an induction date when it wasn't going to be their first choice or they're going to run the risk of having a baby on the side of the road," she said.

Lueking said it's very rare for people to give birth while heading to the hospital in a car or ambulance. But last year, she said, five women who planned to deliver in Pierre ended up delivering in other hospitals' emergency rooms after rapidly progressing labor or weather made it too risky to drive long distances.

Nanette Eagle Star's plan was to deliver at the Winner hospital, five minutes from home, until the hospital announced it would be closing its labor and delivery unit. She then decided to give birth in Sioux Falls, because her family could save money by staying with relatives there.

Eagle Star's plan changed again when she went into early labor and the weather was too dangerous to drive or take a medical helicopter to Sioux Falls.

"It happened so fast, in the middle of a snowstorm," she said.

Eagle Star delivered at the Winner hospital after all, but in the ER, without an epidural pain blocker since no anesthesiologist was available. It was just three days after the birthing unit closed.

The end of labor and delivery services at Winner Regional Health isn't just a health issue, local women said. It also has emotional and financial impacts on the community.

Eagle Star fondly recalls going to doctor appointments with her sisters when she was a child. As soon as they arrived, they'd head to a hallway with baby photos taped to the wall and begin "a scavenger hunt" for Polaroids of themselves and their relatives.

"On both sides it was just filled with babies' pictures," Eagle Star said. She remembers thinking, "look at all these cute babies that were born here in Winner."

Hofeldt said many locals are sad their babies won't be born in the same hospital they were.

Anora Henderson, a family physician, said a lack of maternity care can lead to poor outcomes for infants. Those babies may develop health problems that will require lifelong, often expensive care and other public support.

"There is a community effect," she said. "It's just not as visible and it's farther down the road."

Henderson resigned in May from Winner Regional Health, where she delivered vaginal births and assisted on cesarean sections. The last baby she delivered was Eagle Star's.

To be designated a birthing hospital, facilities must be able to conduct C-sections and provide anesthesia 24/7, Henderson explained.

Williams, the hospital's CEO, said Winner Regional Health hasn't been able to recruit enough medical professionals trained in those skills.

For the last several years, the hospital was only able to offer birthing services by spending about $1.2 million a year on temporary physicians, he said, and it could no longer afford to do that.

Another financial challenge is that many births at rural hospitals are covered by Medicaid, the federal and state program serving people with low incomes or disabilities. The program typically pays about half of what private insurers do for childbirth services, according to a 2022 report by the U.S. Government Accountability Office.

Williams said about 80% of deliveries at Winner Regional Health were covered by Medicaid.

Obstetric units are often the biggest financial drain on rural hospitals, and therefore they're frequently the first to close when a hospital is struggling, the GAO report said.

Williams said the hospital still provides prenatal care and that he'd love to restart deliveries if he could hire enough staff.

Henderson, the physician who resigned from the Winner hospital, has witnessed the decline in rural maternity care over decades.

She remembers tagging along with her mother for appointments before her sister was born. Her mother traveled about 100 miles each way after the hospital in the town of Kadoka shuttered in 1979.

Henderson practiced for nearly 22 years at Winner Regional Health, sparing women from having to travel to give birth like her mother did.

Over the years, she took in new patients as a nearby rural hospital and then an Indian Health Service facility closed their birthing units. Then, Henderson's own hospital stopped deliveries.

"What's really frustrating me now is I thought I was going to go into family medicine and work in a rural area and that's how we were going to fix this, so people didn't have to drive 100 miles to have a baby," she said.

Arielle Zionts: azionts@kff.org, @Ajzionts

Pharmacists find themselves on the front lines of a tariff storm.

This article was published on Friday, May 16, 2025 in KFF Health News.

By Jackie Fortiér and Arthur Allen

In the dim basement of a Salt Lake City pharmacy, hundreds of amber-colored plastic pill bottles sit stacked in rows, one man's defensive wall in a tariff war.

Independent pharmacist Benjamin Jolley and his colleagues worry that the tariffs, aimed at bringing drug production to the United States, could instead drive companies out of business while raising prices and creating more of the drug shortages that have plagued American patients for several years.

Jolley bought six months' worth of the most expensive large bottles, hoping to shield his business from the 10% across-the-board tariffs on imported goods that President Donald Trump announced April 2. Now with threats of additional tariffs targeting pharmaceuticals, Jolley worries that costs will soar for the medications that will fill those bottles.

In principle, Jolley said, using tariffs to push manufacturing from China and India to the U.S. makes sense. In the event of war, China could quickly stop all exports to the United States.

"I understand the rationale for tariffs. I'm not sure that we're gonna do it the right way," Jolley said. "And I am definitely sure that it's going to raise the price that I pay my suppliers."

Squeezed by insurers and middlemen, independent pharmacists such as Jolley find themselves on the front lines of a tariff storm. Nearly everyone down the line — drugmakers, pharmacies, wholesalers, and middlemen — opposes most tariffs.

Slashing drug imports could trigger widespread shortages, experts said, because of America's dependence on Chinese- and Indian-made chemical ingredients, which form the critical building blocks of many medicines. Industry officials caution that steep tariffs on raw materials and finished pharmaceuticals could make drugs more expensive.

"Big ships don't change course overnight," said Robin Feldman, a UC Law San Francisco professor who writes about prescription drug issues. "Even if companies pledge to bring manufacturing home, it will take time to get them up and running. The key will be to avoid damage to industry and pain to consumers in the process."

Trump on April 8 said he would soon announce "a major tariff on pharmaceuticals," which have been largely tariff-free in the U.S. for 30 years.

"When they hear that, they will leave China," he said. The U.S. imported $213 billion worth of medicines in 2024 — from China but also India, Europe, and other areas.

Trump's statement sent drugmakers scrambling to figure out whether he was serious, and whether some tariffs would be levied more narrowly, since many parts of the U.S. drug supply chain are fragile, drug shortages are common, and upheaval at the FDA leaves questions about whether its staffing is adequate to inspect factories, where quality problems can lead to supply chain crises.

On May 12, Trump signed an executive order asking drugmakers to bring down the prices Americans pay for prescriptions, to put them in line with prices in other countries.

Meanwhile, pharmacists predict even the 10% tariffs Trump has demanded will hurt: Jolley said a potential increase of up to 30 cents a vial is not a king's ransom, but it adds up when you're a small pharmacy that fills 50,000 prescriptions a year.

"The one word that I would say right now to describe tariffs is ‘uncertainty,'" said Scott Pace, a pharmacist and owner of Kavanaugh Pharmacy in Little Rock, Arkansas.

To weather price fluctuations, Pace stocked up on the drugs his pharmacy dispenses most.

"I've identified the top 200 generics in my store, and I have basically put 90 days' worth of those on the shelf just as a starting point," he said. "Those are the diabetes drugs, the blood pressure medicines, the antibiotics — those things that I know folks will be sicker without."

Pace said tariffs could be the death knell for the many independent pharmacies that exist on "razor-thin margins" — unless reimbursements rise to keep up with higher costs.

Unlike other retailers, pharmacies can't pass along such costs to patients. Their payments are set by health insurers and pharmacy benefit managers largely owned by insurance conglomerates, who act as middlemen between drug manufacturers and purchasers.

Neal Smoller, who employs 15 people at his Village Apothecary in Woodstock, New York, is not optimistic.

"It's not like they're gonna go back and say, well, here's your 10% bump because of the 10% tariff," he said. "Costs are gonna go up and then the sluggish responses from the PBMs — they're going to lead us to lose more money at a faster rate than we already are."

Smoller, who said he has built a niche selling vitamins and supplements, fears that FDA firings will mean fewer federal inspections and safety checks.

"I worry that our pharmaceutical industry becomes like our supplement industry, where it's the wild West," he said.

Narrowly focused tariffs might work in some cases, said Marta Wosińska, a senior fellow at the Brookings Institution's Center on Health Policy. For example, while drug manufacturing plants can cost $1 billion and take three to five years to set up, it would be relatively cheap to build a syringe factory — a business American manufacturers abandoned during the covid-19 pandemic because China was dumping its products here, Wosińska said.

It's not surprising that giants such as Novartis and Eli Lilly have promised Trump they'll invest billions in U.S. plants, she said, since much of their final drug product is made here or in Europe, where governments negotiate drug prices. The industry is using Trump's tariff saber-rattling as leverage; in an April 11 letter, 32 drug companies demanded European governments pay them more or face an exodus to the United States.

Brandon Daniels, CEO of supply chain company Exiger, is bullish on tariffs. He thinks they could help bring some chemical manufacturing back to the U.S., which, when coupled with increased use of automation, would reduce the labor advantages of China and India.

"You've got real estate in North Texas that's cheaper than real estate in Shenzhen," he said at an economic conference April 25 in Washington, referring to a major Chinese chemical manufacturing center.

But Wosińska said no amount of tariffs will compel makers of generic drugs, responsible for 90% of U.S. prescriptions, to build new factories in the U.S. Payment structures and competition would make it economic suicide, she said.

Several U.S. generics firms have declared bankruptcy or closed U.S. factories over the past decade, said John Murphy, CEO of the Association for Accessible Medicines, the generics trade group. Reversing that trend won't be easy and tariffs won't do it, he said.

"There's not a magic level of tariffs that magically incentivizes them to come into the U.S.," he said. "There is no room to make a billion-dollar investment in a domestic facility if you're going to lose money on every dose you sell in the U.S. market."

His group has tried to explain these complexities to Trump officials, and hopes word is getting through. "We're not PhRMA," Murphy said, referring to the powerful trade group primarily representing makers of brand-name drugs. "I don't have the resources to go to Mar-a-Lago to talk to the president myself."

Many of the active ingredients in American drugs are imported. Fresenius Kabi, a German company with facilities in eight U.S. states to produce or distribute sterile injectables — vital hospital drugs for cancer and other conditions — complained in a letter to U.S. Trade Representative Jamieson Greer that tariffs on these raw materials could paradoxically lead some companies to move finished product manufacturing overseas.

Fresenius Kabi also makes biosimilars, the generic forms of expensive biologic drugs such as Humira and Stelara. The United States is typically the last developed country where biosimilars appear on the market because of patent laws.

Tariffs on biosimilars coming from overseas — where Fresenius makes such drugs — would further incentivize U.S. use of more expensive brand-name biologics, the March 11 letter said. Biosimilars, which can cost a tenth of the original drug's price, launch on average 3-4 years later in the U.S. than in Canada or Europe.

In addition to getting cheaper knockoff drugs faster, European countries also pay far less than the United States for brand-name products. Paradoxically, Murphy said, those same countries pay more for generics.

European governments tend to establish more stable contracts with makers of generics, while in the United States, "rabid competition" drives down prices to the point at which a manufacturer "maybe scrimps on product quality," said John Barkett, a White House Domestic Policy Council member in the Biden administration.

As a result, Wosińska said, "without exemptions or other measures put in place, I really worry about tariffs causing drug shortages."

Smoller, the New York pharmacist, doesn't see any upside to tariffs.

"How do I solve the problem of caring for my community," he said, "but not being subject to the emotional roller coaster that is dispensing hundreds of prescriptions a day and watching every single one of them be a loss or 12 cents profit?"

Jackie Fortiér: jfortier@kff.org, @JackieFortier

Arthur Allen: aallen@kff.org, @ArthurAllen202