The Price of Trust

Last week, I wrote about the ongoing shortage of estrogen patches and the women who are struggling to get their hands on a medication that has dramatically improved their quality of life.

From my desk above the pharmacy at C.O. Bigelow, I hear these conversations every day. Women who have finally found relief from debilitating menopause symptoms are now being told that their medication is unavailable. Sometimes we can find an alternative. Sometimes we can't.

What patients never see is the work that happens before that conversation. We call our wholesalers, plural, because the first two are usually out of it too. We call other pharmacies. We go back to the prescriber with whatever alternatives exist. By the time a shortage reaches the counter, it is the end of a long chain of phone calls nobody ever hears about.

I wrote that the experience makes me feel incredibly stupid being the face of American healthcare.

Then, a few days later, John Oliver devoted the main segment of Last Week Tonight to generic medications, their manufacturing, and the increasingly fragile supply chain responsible for producing the drugs Americans depend on.

If you haven't watched it, I strongly encourage you to spend 23 minutes doing so.

Oliver's segment is funny, disturbing, and remarkably effective at explaining a problem most Americans have probably never considered.

It also connects to something I've been writing about since launching Drugstore Cowboy: 

Our healthcare system has become extraordinarily efficient at moving money around, but increasingly unreliable at delivering the actual care that money is supposed to buy.

More than 90% of prescriptions dispensed in the United States are for generic medications.

That's generally a wonderful thing. Generic drugs have saved the American healthcare system trillions of dollars. Once a brand-name medication loses exclusivity, other manufacturers can produce equivalent versions at a fraction of the price, sometimes pennies per pill.

But Oliver asks a question that deserves more attention: What happens when we make medications so cheap that nobody wants to manufacture them anymore?

Healthcare is a business, and the generic drug business is brutally competitive. Manufacturers compete for contracts with buyers primarily interested in securing the lowest possible price. Margins shrink. Manufacturers consolidate or abandon certain products altogether. Eventually, a medication that millions of people depend on might be produced by only one or two companies.

Then something goes wrong. A factory fails an inspection. A production line shuts down. Suddenly, a medication that has existed for decades becomes almost impossible to find.

In 2019, when one of the few manufacturers of vincristine, a chemotherapy drug used to treat childhood cancers, stopped producing it, the remaining supplier couldn't meet demand. I shouldn’t have to explain the consequences to that. More recently, shortages of critical chemotherapy drugs followed serious manufacturing violations at facilities operated by the Indian pharmaceutical company Intas.

These weren't experimental medications or expensive new therapies. They were established, essential generic drugs that the healthcare system had relied upon for years. 

Maybe we took their availability for granted.

Oliver also examines the quality of generic medications manufactured overseas. A substantial portion of the American generic drug supply comes from India, while China plays an important role in producing active pharmaceutical ingredients. My longtime readers already know this.

He describes overseas facilities where inspectors discovered destroyed quality-control records, improper storage conditions, and serious manufacturing violations.

He also references a 2025 study published in Production and Operations Management, which found that generic drugs manufactured in India were associated with approximately 54% more reported serious adverse events than comparable American-made products. The difference was concentrated in older generic drugs, where years of price competition have placed the greatest pressure on manufacturers.

There are important limitations to that research. Adverse-event reports cannot establish causation, and manufacturing location alone doesn't determine drug quality. Plenty of overseas facilities operate to exceptionally high standards.

Still, the documented manufacturing failures are troubling.

Oliver features a heart transplant recipient whose blood levels of tacrolimus, an immunosuppressant used to prevent organ rejection, reportedly fluctuated dramatically after switching generic manufacturers. He also recounts the deadly 2023 outbreak associated with contaminated eye drops manufactured in India.

We've created a system where price is actually acceptable, but manufacturing quality is much harder to evaluate.

Before going any further, I want to make something clear.

I am not suggesting that you should be afraid of your generic medications.

The overwhelming majority of generics dispensed in the United States are safe and effective. I dispense them every day. I take them myself and recommend them to my family. Please don't stop taking prescribed medication because you watched a television segment or read this newsletter.

And if your pills suddenly look different, ask your pharmacist whether the manufacturer has changed. That doesn't automatically mean anything is wrong, but it's a reasonable question.

My goal isn't to create panic. It's to explain where the system has weaknesses and what we might do to improve it.

One obvious solution is to bring more pharmaceutical manufacturing back to the United States.

This isn't simply about patriotism or American jobs. It's about national security, supply-chain resilience, and regulatory oversight.

We depend on medications to keep millions of Americans alive, yet much of the infrastructure responsible for manufacturing them sits thousands of miles away. In the event of a geopolitical conflict or major supply-chain disruption, that dependence could become a serious vulnerability.

But there's another advantage to domestic manufacturing that deserves more attention.

It's considerably easier for the FDA to inspect a manufacturing facility in North Carolina than one halfway around the world.

Inspectors don't have to navigate international travel, visas, foreign governments, and the logistical complications of investigating factories overseas. That doesn't guarantee better manufacturing practices, but it makes oversight more practical.

I've written extensively about the FDA's declining resources, usually in the context of compounding pharmacies and unapproved drugs marketed directly to consumers.

But Oliver's segment illustrates that the FDA's inspection problem existed long before the current administration began cutting its workforce. We spent decades expanding the supply chain's complexity without building the regulatory infrastructure to keep pace. Recent staffing reductions threaten to make an existing problem worse.

Of course, bringing manufacturing back to America is easier said than done.

In December 2025, Mark Cuban was urging the Trump administration to waive FDA application fees to encourage domestic generic drug production.

Cuban, whose Cost Plus Drugs company operates a pharmaceutical compounding facility in Dallas, said his company would be willing to manufacture certain generics domestically if those fees were eliminated.

At the time, the FDA charged nearly $360,000 per generic drug application.

Think about that. If you're considering manufacturing an inexpensive generic medication with a relatively small market, you're potentially spending hundreds of thousands of dollars on the regulatory application alone, before facilities, equipment, staffing, and ongoing compliance.

Then you enter a purchasing environment that rewards whoever can sell the finished product for the lowest price.

We've made it extremely difficult and expensive to enter the generic manufacturing business, then structured the market to make that business as unprofitable as possible.

And we wonder why manufacturers keep leaving.

I'm not advocating weaker FDA standards. But fee relief, targeted incentives, and guaranteed purchasing contracts for essential drugs could make domestic manufacturing more viable.

We already recognize certain industries as strategically important enough to justify government support.

Surely manufacturing the medications keeping Americans alive belongs on that list.

There's another part of Oliver's segment that struck me, because it's something I think about constantly while running C.O. Bigelow.

He points patients toward tools such as ProPublica's Rx Inspector, which allows people to investigate the manufacturers of their generic medications and review available FDA inspection histories.

I think greater transparency is wonderful. But the idea of patients investigating pharmaceutical factories halfway around the world strikes me as a rather absurd expectation.

You shouldn't need to become an amateur FDA investigator to feel comfortable taking your blood pressure medication.

That's supposed to be our job, or at least something pharmacists should be better equipped to help patients with.

Yet much of modern pharmacy has been reduced to a transactional exercise. Fill the prescription. Process the insurance claim. Get the patient out the door. And do it all as cheaply and quickly as possible.

At C.O. Bigelow, we try to operate differently.

We pay attention to the manufacturers of the generic medications we purchase. We work with reputable suppliers, consider manufacturers' track records, and try to maintain consistency in the products we dispense.

We do not automatically purchase the cheapest generic medication available.

When we have a choice between a manufacturer we know and trust and an unfamiliar alternative that might save us a little money, price isn't the only consideration.

And when a patient has been stable on a particular manufacturer's product, we try not to change it unnecessarily.

For certain medications, particularly those with narrow therapeutic indexes, consistency can be especially important. Switching manufacturers isn't automatically dangerous, but it can warrant closer attention and sometimes additional monitoring.

Of course, there are limits to what we can accomplish.

Even a conscientious independent pharmacy doesn't have access to every manufacturing record or quality-control test performed on every batch of medication it purchases. A manufacturer's reputation isn't a substitute for laboratory testing, and professional judgment cannot independently establish the quality of a finished drug.

We still depend on manufacturers, wholesalers, and regulators.

But there's a meaningful difference between a pharmacy that makes an effort to understand what it's purchasing and one that treats every FDA-approved generic as an interchangeable commodity whose only distinguishing characteristic is price.

And I suspect that difference may eventually become an entirely new business model.

I've spent much of the past year and a half writing about how the economics of pharmacy are changing.

In my very first Drugstore Cowboy newsletter, I explained how my pharmacy spent more than $2 million purchasing GLP-1 medications over the course of a year, only to lose approximately $26,000 dispensing them.

I've written about pharmacy benefit managers and the financial incentives making it increasingly difficult for independent pharmacies to survive. I've argued that healthcare has become a consumer product, something patients are expected to shop for, purchase, and manage themselves. And last week, I described how women struggling to obtain estrogen patches are being forced to navigate shortages and bureaucracy that should never be their responsibility.

All of these stories are connected.

We've built a healthcare system obsessed with reducing the price of individual transactions, often without accounting for the value of the care, reliability, and expertise surrounding them.

And I think that creates an opportunity.

Imagine a pharmacy that doesn't simply promise to fill your prescription quickly or deliver it to your apartment.

Imagine one that independently evaluates the generics it carries. That pays for third-party laboratory testing of selected products, tracks manufacturing sources and regulatory violations, and provides patients with meaningful information about the medications they're taking.

A pharmacy that can explain not just what a medication does, but why it chose to purchase that particular manufacturer's version.

That would require real investment. Testing is expensive, and no pharmacy could test one pill and declare an entire manufacturer's products safe.

But I believe there would be patients willing to pay for a meaningful additional layer of scrutiny.

Maybe it's a membership. Maybe it's a premium service. Maybe it's part of a broader model where patients pay directly for professional pharmacy care rather than expecting everything to be financed through the margin on a prescription. I’m just thinking out loud.

To be clear, Bigelow is not that pharmacy today. Watching manufacturers, refusing to chase the cheapest generic, and maintaining consistency for our patients are as far as a store like ours can reasonably go on its own.

The rest would require infrastructure that doesn't yet exist in a form readily available to independent pharmacies.

But trust may become one of the most valuable things a pharmacy can offer.

There's something haunting about saying that in the United States in the year 2026.

Patients shouldn't have to pay extra to know their medications were manufactured properly. They shouldn't need a premium subscription to receive drugs from reputable manufacturers. That should be the responsibility of the FDA.

But I've spent enough time behind a pharmacy counter to know that what should happen and what does happen are often two very different things.

If regulators cannot provide the transparency patients deserve, someone will eventually build a business around providing it. Maybe an independent pharmacy. Maybe a national chain. Maybe a company that doesn't exist yet.

And I suspect people will pay.

We've spent decades making generic medications cheaper, only to potentially create a market where patients pay more simply to trust what's inside the bottle.

That seems like a rather expensive way to discover what our healthcare system should have been providing all along.

Giddy up!

Alec Wade Ginsberg, PharmD, RPh
4th-Gen Pharmacist | Owner & COO, C.O. Bigelow
Founder, Drugstore Cowboy