The United States continues to experience significant fragility in its pharmaceutical supply chain, with 216 active drug shortages reported in 2025. Public discussion increasingly frames resilience as a national security issue, often emphasizing U.S.-China competition. This piece argues that while China plays a dominant role in production, the immediate and primary risks to securing medicines are regulatory and structural — not simply geopolitical. Strengthening governance and public health infrastructure should therefore be the central priority.
China is heavily involved across upstream inputs and finished pharmaceutical products, prompting concern about dependence. However, the shortage and scarcity of inputs are not equivalent to exhaustion of a finite natural resource. Instead, the article contends these dynamics reflect an industry that has shifted production toward lower-cost jurisdictions in response to profit incentives. Analogies between pharmaceutical inputs and inherently limited critical minerals are therefore flawed, because pharmaceutical scarcity often stems from commercial choices and regulatory environments rather than resource exhaustibility.
Past incidents illustrate how regulatory shortcomings — both for products made abroad and domestically — have endangered U.S. patients. Notable examples include contamination of Baxter’s heparin product in 2008, linked to ingredients sourced from China, which resulted in more than 150 adverse events including severe allergic reactions and deaths. Another example is the 2012 fungal meningitis outbreak caused by unsanitary practices at a U.S. compounding pharmacy (New England Compounding Center), which affected over 750 patients and led to 64 deaths. These events are cited to show that weak regulation and enforcement, not deliberate foreign coercion, have been proximate causes of harm.
Effective diversification and secure supplies require robust public health and regulatory infrastructure. The Food and Drug Administration performs essential tasks such as tracking drug supplies, monitoring sources and quality of imports, and setting standards for domestic manufacturing. Yet the FDA is described as falling short on transparency, efficacy, and safety enforcement. Recent staffing turnover and reductions are highlighted as exacerbating these gaps, along with proposals that may prioritize speed over standards.
Reductions in National Institutes of Health funding and politicization of federal research grant approvals are additional concerns. Publicly funded R&D supports pharmaceutical innovation and resilience; threats to NIH funding and the integrity of grant processes jeopardize the broader research ecosystem. New initiatives intended to boost U.S. R&D competitiveness, such as cross-agency reforms, risk failing if they do not address these underlying structural problems.
Policy proposals focusing on onshoring or friend-shoring specific inputs or products assume that relocating production will ensure security. The article argues this is insufficient without concurrent investments in regulatory and public health systems. Onshoring without cohesive health policy and oversight will simply shift vulnerabilities to domestic plants and companies that may also operate as single points of failure. Moreover, the move could increase costs in a health system already burdened by high drug prices.
A major domestic vulnerability is consolidation: relatively few companies or even single plants often supply the majority of critical health products. An example discussed is the temporary IV fluid shortage after Hurricane Helene, where damage to a Baxter plant in North Carolina disrupted supplies because that plant supplied a large share of national IV fluids. The article notes that the U.S. also imported IV fluids temporarily from the U.K., Canada, and China as stopgaps. Thus, securing supply requires addressing corporate consolidation and reducing reliance on single companies or facilities, whether those facilities are located domestically or overseas.
Efforts to incentivize onshoring through tariffs are likely to raise medication prices. The U.S. government’s pharmaceutical tariffs scheduled to take effect were intended to encourage domestic production, but analyses referenced suggest substantial tariffs could increase drug prices materially — and proposals to have programs like Medicare Part B absorb additional costs risk worsening affordability for beneficiaries. The article emphasizes that isolating onshoring policies from broader measures to make health care affordable — such as government drug price negotiation or expanded coverage — would exacerbate barriers to access and public health vulnerabilities.
The central recommendation is that resilience in the pharmaceutical supply chain will not be achieved through a narrow geopolitical lens alone. While excessive reliance on any single country can pose risks amid geopolitical tensions, anchoring policy primarily on U.S.-China competition overlooks domestic structural problems. The article calls for regulatory reforms that prioritize safety, transparency, and public health above corporate profit, strengthened FDA and NIH capacities, measures to reduce single-source dependencies, and affordability policies to prevent higher costs from undermining access. Only a comprehensive approach that addresses regulatory and structural drivers will materially improve supply chain resilience.