Most of us in day to day pharmacy practice don’t spend much time thinking about where the drugs on our shelves come from. There’s too much else happening, the queue, the prior auth, the patient at the window, the phone ringing.
But some of the sharpest minds in pharmacy just put a warning on the table that deserves more than a passing glance.
What ASHP’s Pharmacy Forecast 2026 Actually Said
Five contributors to the ASHP and ASHP Foundation’s Pharmacy Forecast 2026 sounded a warning to the pharmacy industry during a session at ASHP Midyear 2025: that pharmacists and their health systems are uncertain about the future and unprepared for crises that may arise before the end of the decade.
One of the most striking data points from the session was about domestic manufacturing capacity. About 28% of active pharmaceutical ingredient (API) production serving the US market is performed domestically. Respondents were asked to predict whether 50% of that production would move to the US by 2030. A majority, 61%, considered this unlikely, with one contributor agreeing that the cost to build manufacturing capacity in the United States is much higher than in other countries.
And then there was the comment that should make every pharmacist pay attention. Tom Kraus, JD, vice president of Government Relations for ASHP, said he expects Congress to debate drug shortages, but that the issue “is never a priority for Congress until it absolutely is.” His greater concern was over national security and the drug supply chain: “China is potentially preparing to engage in some kind of conflict over Taiwan in 2027,” he said.
That is not a talking point from a cable news pundit. That is the VP of Government Relations for the nation’s leading health-system pharmacy organization raising it at a major professional conference as a real supply chain risk.
The Numbers Behind the Vulnerability
To understand why this matters so much, you need to understand just how concentrated the global pharmaceutical supply chain is.
Roughly 70–80% of global API production is concentrated in India and China, and many Western manufacturers depend heavily on those sources. Moving API production for a complex molecule can take three to five years. APIs remain the most exposed and least flexible layer of the pharmaceutical supply chain.
And the India, China link is deeper than most people realize. India depends on China for approximately 70% of its bulk drug and intermediate imports. This indirect reliance means many pharmaceutical products originating from India still contain Chinese raw materials, making true diversification an ongoing challenge.
The practical impact on the US pharmacy shelf is sobering. Most large-scale manufacturing sites for APIs are in China and India, while less than 5% of large-scale API sites globally are in the US. Of the top 100 generic medicines prescribed in this country, 83 have no US source of API.
Roughly 20% of critical drugs have APIs exclusively sourced from China. Even medications stamped “Made in America” or “Made in India” are often chemically Chinese in origin. And 40% of US generic drugs have only one FDA-approved manufacturer, meaning even finished drug production is frequently a single-source vulnerability.
This Just Got More Complicated: April 2026 Tariff Announcement
The story escalated significantly just weeks ago. On April 2, 2026, the Trump administration announced a 100% base tariff on imported APIs and patented drugs, with transitional relief available for companies committing to onshoring, and lower rates for companies from countries with trade agreements. Commerce Department Section 232 findings framed pharmaceutical import dependence as a national security risk, specifically citing concentrated API production in China and India and potential export leverage.
The tariffs are intended to drive reshoring. But the honest assessment from supply chain experts is that the timeline mismatch is severe. One supply chain CEO noted: “We’re seeing a concern where the medicine supply chain could be used with trade tools as, almost weaponized, and that creates a vulnerability that I think we’re not comfortable with from the perspective of both national security and, of course, patient care.”
And there is no quick fix. Companies will need stronger capabilities in network design, planning, trade compliance, and supplier visibility. The goal is not just optimization, but adaptability. This environment cannot be managed with static planning models.
Why the Drug Shortage Situation Is Still Unresolved
You may be thinking we’ve had drug shortages before and navigated through. That’s true. But the current baseline is not reassuring.
Three-quarters of all active shortages (75%) started in 2022 or later. Lower numbers of shortages do not necessarily translate into fewer patients impacted, as a single shortage can impact large numbers of patients. The workload required to manage shortages, including work to change pharmacy automation and electronic health records, adds to the challenges of pharmacy staff shortages.
Generic drug products are particularly susceptible to shortages because redundancy is typically not built into the production process. Generic products are manufactured on lines that prepare multiple products, and an additional manufacturing line is generally not available as a contingency.
In other words: the infrastructure for weathering a major supply disruption is thin, the concentration risk is real, and the geopolitical pressure is rising all at the same time.
What This Actually Means for You at the Counter
This is not a story that resolves itself at the policy level and leaves pharmacy practice untouched. When a supply chain disruption happens, whether from a geopolitical event, a manufacturing quality failure, a weather disaster, or a tariff-driven price shock, it’s the pharmacist who fields the call from the patient, the prescriber, and the wholesaler simultaneously.
Here is what you can do right now to be ahead of it rather than reactive:
Know your top 30 dispensed medications by supply chain vulnerability. Go through your highest-volume generics and ask: is this single-source? Is it primarily manufactured overseas? Is there a therapeutic alternative? You don’t need to answer all three perfectly, you just need to know which ones carry the most risk so you’re not figuring it out in the middle of a shortage.
Build a real relationship with your wholesaler rep. Not just a transactional one. The reps who like their accounts call them first when allocation starts. Get on that list before you need to be.
Bookmark ASHP’s drug shortage database at ashp.org/drug-shortages. It’s updated continuously and is more comprehensive than the FDA’s list, including shortages the FDA doesn’t formally report. Make it part of your weekly workflow, not something you check when the problem has already arrived.
Have a substitution protocol in place before you need it. For your highest-risk medications, antibiotics, oncology supportive care, injectables, psychiatric medications, know the alternatives ahead of time. The therapist managing a patient on a shortage medication will thank you for having a plan.
The Bigger Picture
The ASHP panelists said it plainly: drug shortages are never a Congressional priority until they absolutely are. The same logic applies to how most of us manage supply chain risk, it doesn’t feel urgent until a patient is standing in front of you asking why you can’t fill their medication.
The structure of the problem, overwhelming API dependence on countries with rising geopolitical risk, minimal domestic manufacturing redundancy, thin margins that discourage buffer stock, is not going to be fixed in the next 13 months. What can change in 13 months is how well you and your pharmacy are positioned to handle what comes.
The pharmacists who build supply chain intelligence into their operations now, not as a reaction to a crisis, but as a standing practice, will be the ones their communities and prescribers lean on when things get complicated.
Sources: Pharmacy Times (ASHP Pharmacy Forecast 2026 Deep Dive), American Journal of Health-System Pharmacy / Oxford Academic (ASHP Pharmacy Forecast 2026 report), ASHP Drug Shortage Statistics, Brookings Institution (China’s Role in US Drug Supply Chains; When Medicine Supply Chains Become Weapons), Pharmaceutical Commerce, Pharmaceutical Technology, Logistics Viewpoints, CSIS, Pharma Manufacturing