The Hollowing Out of America’s Medicine Cabinet

Solid-dose tablets suffer the same market dynamics and price pressure as liquid suspensions and every other generic. These are the country’s daily maintenance medicines, and America has allowed their production to be offshored to an alarming degree. The same forces and foreign production pressure are at work: subsidized foreign overcapacity, a market that pays the lowest bid and nothing for resilience, and a domestic base that thinned one exit at a time until the country found itself dependent on factories an ocean away.

Consider eleven of these tablets: amlodipine and hydrochlorothiazide for high blood pressure; spironolactone for heart failure; glipizide for type 2 diabetes; sotalol for cardiac arrhythmia; primidone for seizures and essential tremor; trazodone, buspirone, and imipramine for depression, anxiety, and insomnia; and methocarbamol and carisoprodol for muscle spasm. These are high-volume staples, with amlodipine and hydrochlorothiazide alone running tens of millions of prescriptions a year [23].

The mechanism that hollowed out their production is well documented, even if the government has been slow to address the issue. FDA’s 2019 Drug Shortages Task Force examined 163 drugs that fell into shortage and concluded that shortages are primarily the consequence of economic factors, led by a lack of incentives to produce less profitable drugs — noting that many shortages began with the outright discontinuation of products for reasons like low drug price [24]. 

The price data show why. On CMS’s National Average Drug Acquisition Cost benchmark — the invoice price pharmacies actually pay — hydrochlorothiazide runs about a penny per tablet, amlodipine roughly a penny and a half, and buspirone about three cents [25]. These prices are continuing to be pushed down by import pressure. Year-over-year deflation on all generic oral-solid tablets is at 13.4% [26], with even more acute price pressure for discontinued oral-solid medicines, where the median price has dropped 78% in a single year [12]. At those declining prices there is no margin for redundancy and no investment case for increasing domestic production without a strong policy signal. In fact, these prices are the reason behind declining domestic production and product line discontinuation. USP found that two-thirds of discontinued oral-solid drugs were priced below $1 per unit [12].

Spironolactone illustrates the point. Par discontinued its tablet products in 2018 [27], and Pfizer later discontinued brand-name Aldactone in late 2025 as a business decision; in both cases, product exits contributed to meaningful supply disruptions [28]. Methocarbamol, a common muscle relaxant, shows the same fragility: shortages followed product discontinuations by Par and Virtus, then deepened when a remaining supplier faced an active-ingredient disruption [29]. Some manufacturers have made the strategy explicit. At its 2023 investor day, Teva said it would stop chasing the lowest-margin generics, backing away from low-cost products where intense price pressure had made the business unsustainable [30]. One by one, the companies that keep these tablets on American shelves are deciding that prices no longer justify the cost, complexity, and risk of staying in the market.

The clearest picture of what these decisions cost for a community sits in Morgantown, West Virginia. For decades, the Mylan — later Viatris — plant at Chestnut Ridge was one of the largest generic pharmaceutical factories in the country, operating since 1965 and providing well-paid manufacturing jobs in one of America’s lower-income states. In 2021, Viatris closed the plant as part of a global restructuring plan, eliminating roughly 1,500 to 2,000 jobs and sending work overseas, including to India [31]. Union officials estimated the closure would strip $150 million to $200 million in lost income from north-central West Virginia, and described the plant as one of the last major generic-manufacturing anchors in the United States [31]. Chestnut Ridge shows how production closures and offshoring create real economic consequences for communities across the country that extend beyond pharmacies and hospitals. 

Morgantown is not an isolated story. In 2016 and 2017, Endo closed its Charlotte, North Carolina plant and its Huntsville, Alabama complex — 875 jobs at Huntsville alone — discontinuing more than 60 products and citing “greater than expected price erosion across the generics sector.” Amneal shuttered its Hayward, California facility in 2018, cutting roughly 550 jobs. Teva permanently exited its Irvine, California sterile injectables plant in 2022, laying off 305 workers. Akorn filed for Chapter 7 bankruptcy in February 2023 and closed every U.S. site — Decatur, Illinois; Somerset, New Jersey; Amityville, New York — terminating some 400 workers with no severance. Sandoz closed its Wilson, North Carolina tablet plant in 2024, eliminating 213 jobs after concluding the site could no longer produce at cost-effective volumes. And in June 2024, Jubilant Cadista closed its 1.5-billion-dose Salisbury, Maryland facility, stating that U.S. generic pricing pressure had made domestic manufacturing unprofitable — it now supplies the U.S. market from plants abroad.

The result of all these production closures amid suppressed and unsustainable margins is a thin and fragile generic supply base. Of 1,838 small-molecule drugs in 2022, 43% had only one manufacturer and another 16% had just two or three [32]. That means nearly 60% of small-molecule drugs had three or fewer manufacturers — a structure that has little room for a product line exit, quality hold, or demand shock.

That fragility matters because these are not optional medicines. They are daily maintenance drugs, taken indefinitely by patients whose health depends on uninterrupted supply. For example, a sotalol patient cannot simply restart after a gap; because the drug can itself trigger dangerous arrhythmias, FDA labeling requires at least three days of in-hospital cardiac monitoring when therapy is initiated or re-initiated [33]. A primidone interruption can mean breakthrough seizures [34], and a glipizide gap can destabilize blood sugar in a diabetic senior [35]. When a maintenance drug goes short, the problem is not a delayed treatment course — it is the disruption of ongoing therapy for millions of patients, often seniors on fixed incomes who are least able to chase scarce medicine across pharmacies or pay for additional medical care.

The same pattern leads back to imports. Price pressure, product discontinuations, and shortages are all intensified when low-cost foreign supply captures the market and domestic production thins out. The United States now relies on imports for 78% of its solid oral generics [36], and that dependence is highly concentrated. As Figure 4 shows, India supplied 68.5% of U.S. import volume across the tariff lines covering these key solid-dose tablet medicines from January 2025 through April 2026, compared with 16.6% from the EU and EFTA and 6.9% from China [2]. That leaves the United States dangerously reliant on a single country for a large share of its generic drug supply — a strategic risk made clearer during COVID, when India restricted exports of medicines and ingredients amid the crisis [37].