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?”

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The lobby at this St. John’s Community Health clinic in South Los Angeles bustles with patients. But community health worker Ana Ruth Varela is worried that it’s about to get a lot quieter. Many patients, she said, are afraid to leave their homes.

“The other day I spoke with one of the patients. She said: ‘I don’t know. Should I go to my appointment? Should I cancel? I don’t know what to do.’ And I said, ‘Just come.’”

Since Donald Trump’s return to the White House, fear of mass deportations carried out by U.S. Immigration and Customs Enforcement has gripped immigrant communities.

For years, a long-standing policy prevented federal immigration agents from making arrests at or near sensitive locations, including schools, places of worship, hospitals, and health centers. It was one of the first policies Trump rolled back in January, just hours after his inauguration.

Acting Department of Homeland Security Secretary Benjamine Huffman revoked the directive on Jan. 21. In an accompanying press release, a DHS spokesperson said the action would assist agents searching for immigrants who have committed crimes. “The Trump Administration will not tie the hands of our brave law enforcement, and instead trusts them to use common sense,” the statement said.

The speed of the change took Darryn Harris by surprise.

“I thought we had more time,” said Harris, chief government affairs and community relations officer for St. John’s.

Harris is racing to teach more than 1,000 St. John’s workers how to read warrants as they train for a new role — teaching patients their constitutional rights.

California Attorney General Rob Bonta, a Democrat, is advising clinics to post information about patients’ right to remain silent and to provide patients with contact information for legal-aid groups.

Bonta is also urging health care providers to avoid including patients’ immigration status in bills and medical records. His office directs that while staff should not physically obstruct immigration agents, they are under no obligation to assist with an arrest.

Even though immigration arrests took place in hospitals during Trump’s first term, the overall policy was still one of deference to “sensitive locations.” Now, however, DHS states that the previous rules hindered law enforcement efforts by creating sites where people without legal status could evade capture.

Matt Lopas, director of state advocacy and technical assistance for the National Immigration Law Center, said that in order for immigration officers to access health information or go into private spaces such as exam rooms, they must present a warrant signed by a judge.

“It’s incredibly important that every health care center has somebody who is trained to be able to read those warrants” and determine their validity, Lopas said.

In the San Francisco Bay Area, Zenaida Aguilera has been tapped to read warrants for La Clínica de La Raza. She is the compliance, privacy, and risk officer for the clinic network. If immigration agents show up, she’s on call for all 31 of the organization’s community clinics.

Aguilera is also now in charge of training hundreds of health staffers. She has trained about 250 thus far, but the majority of that work is yet to come.

“We have about, probably, a thousand more staff,” she said.

She fears the Trump administration will target California for immigration enforcement because of its approximately 2 million residents without legal status, the highest of any state, according to the Pew Research Center. In 2022, 11 million people were in the U.S. without authorization.

Aguilera said La Clínica plans to post patients’ constitutional rights in clinic lobbies and will provide resources such as contact information for legal-aid groups.

“We would like to just do the work of caring for our patients rather than train our staff on what to do if there’s an ICE official that tries to come into our clinics,” Aguilera said.

This article is from a partnership that includes NPR and KFF Health News.

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This spring, a few days after his 2nd birthday, Brigland Pfeffer was playing with his siblings in their San Diego backyard.

His mother, Lindsay Pfeffer, was a few feet away when Brigland made a noise and came running from the stone firepit, holding his right hand. She noticed a pinprick of blood between his thumb and forefinger when her older son called out, “Snake!”

“I saw a small rattlesnake coiled up by the firepit,” she said.

Pfeffer called 911, and an ambulance transported Brigland to Palomar Medical Center Escondido.

The Medical Procedure

When they arrived, Brigland’s hand was swollen and purple.

Antivenom, an antibody therapy that disables certain toxins, is usually administered via an intravenous line, directly into the bloodstream. But emergency room staffers struggled to insert the IV.

“They had so many people in that room trying his head, his neck, his feet, his arms — like, everything to find a vein,” Pfeffer said.

Still unable to start the antivenom, a doctor asked for her permission to try drastic measures. “Just get something going,” she recalled pleading.

It worked. Using a procedure that delivers medicine into the bone marrow, the medical team gave Brigland a starting dose of the antivenom Anavip.

He was transferred to the pediatric intensive care unit at Rady Children’s Hospital, where he received more Anavip.

The swelling that had spread to his armpit slowly decreased. A couple of days later, he left the hospital with his grateful parents.

Then the bills came.

The Final Bill

$297,461, which included two ambulance rides, an emergency room visit, and a couple of days in pediatric intensive care. Antivenom alone accounts for $213,278.80 of the total bill.

The Billing Problem: The High Cost of Antivenom

The Centers for Disease Control and Prevention estimates venomous snakes bite 7,000 to 8,000 people in the United States every year. About five people die. That number would be higher, the agency says, if not for medical treatment.

Many snakebites happen far from medical care, and not all emergency rooms keep costly antivenom in stock, which can add big ambulance bills to already expensive care.

It often takes more than a dozen vials, typically costing thousands per vial, to treat a snakebite. The median number per patient is 18 vials, said Michelle Ruha, an emergency room doctor in Arizona and a former president of the American College of Medical Toxicology.

Manufacturing, which hasn’t fundamentally changed since antivenom was developed more than a century ago, does not explain the high price. Venomous creatures are milked, then a small, non-harmful amount of toxin is injected into animals like horses or sheep. Antibodies are extracted from their blood and processed to make antivenom.

Why the high price? One explanation is that hospitals mark up products to balance overhead costs and generate revenue.

Brigland received Anavip at two hospitals that charged different prices.

Palomar, where emergency staffers treated Brigland, charged $9,574.60 per vial, for a total of $95,746 for the starting dose of 10 vials of Anavip.

Rady, the largest children’s hospital on the West Coast, charged $5,876.64 for each vial. For the 20 vials Brigland received there, the total was $117,532.80.

Neither hospital responded to requests for comment.

Those charges are “eye-popping,” said Stacie Dusetzina, who is a professor of health policy at Vanderbilt University Medical Center and reviewed the bills at the request of KFF Health News. “When you see the word ‘charges,’ that’s a made-up number. That isn’t connected at all, usually, to what the actual drug cost.”

For instance, Medicare — the government program for those who are at least 65 or disabled — pays about $2,000 for a vial of Anavip. On average, Dusetzina said, that is the price hospitals pay for it.

Leslie Boyer, a doctor and toxicology researcher, helped found a group that was instrumental in developing Anavip, as well as the other available snake antivenom, CroFab, which dominated the market for decades. In 2015, she published an editorial in the American Journal of Medicine breaking down the “true” cost of antivenom. (Boyer declined to comment for this article.)

Using cost data collected from factory supervisors, animal managers, hospital pharmacists and other sources, Boyer developed a model for a hypothetical antivenom, at a final cost of $14,624 per vial. She found the cost of venom, included in that total, was just 2 cents. Manufacturing accounted for $9 of the $14,624 total.

More than 70% of the price tag — $10,250 — is attributable to hospital markups, her research showed.

Another explanation for antivenom’s high cost is a lack of meaningful competition. Anavip entered the market in 2018 as the only competitor to CroFab. But its makers settled a patent infringement lawsuit with CroFab’s maker, requiring the makers of Anavip to pay royalties until 2028.

Anavip debuted at a retail price of $1,220 per vial. Boyer noted that the price later rose to cover the manufacturers’ millions of dollars in legal costs.

The Resolution

The insurer covering Brigland — Sharp Health Plan, which did not respond to requests for comment — negotiated down the antivenom charges by tens of thousands of dollars.

The cost was mostly covered by insurance. Brigland’s family paid $7,200, their plan’s out-of-pocket maximum.

Insurance did not pay all the claims, including one ambulance bill. Pfeffer said she received a letter this summer indicating they owe an additional $11,300 for Brigland’s care. While the landmark No Surprises Act protects patients from many out-of-network bills in emergencies, the law controversially exempted bills for ground ambulances.

Brigland’s hand healed, though nerve damage and scar tissue have left his right thumb less dexterous. He is now left-handed.

“He’s very, very lucky,” Pfeffer said.

The family has since installed snake fencing around the yard.

The Takeaway

There’s a saying in toxicology: Time is tissue. If bitten by a snake, “get to medical care,” Ruha said.

Not all emergency rooms have antivenom, and there are no online resources identifying which ones do. Ruha recommends going to a large hospital, which is more likely to have antivenom in stock than free-standing emergency rooms.

When the bill comes, be ready to negotiate, Dusetzina said. Providers know their charges are high and may be willing to take less.

You can compare the charges against average prices using cost estimation tools like Fair Health Consumer or Healthcare Bluebook.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!