The Trump administration’s escalating calls for drug companies to lower prices underscore just how stuck the industry is in its role as corporate villain — even though Big Pharma is only one part of an exceedingly complex system.

The optics may be politically effective, but they do little to address the underlying mechanics of drug pricing — or help the industry explain why fixing its reputation isn’t as simple as slashing costs.

Drug companies, of course, remain wildly profitable. Fierce Pharma called 2024 “a remarkable year of revenue growth for the industry,” with six of the top 20 companies registering double-digit growth including Eli Lilly (32%) and Novo Nordisk (26%). Merck & Co. reported roughly $64.17 billion in FY2024 revenue, topping the list of pharmaceutical firms. Pfizer ($63.63 billion), Johnson & Johnson (pharma revenue of $57.07 billion), AbbVie ($56.33 billion) and AstraZeneca ($54.07 billion) followed.

Yet with all their resources, Big Pharma has yet to figure out how to tell its side of the story, let alone persuade Americans that drug companies are not the only player in a tangled system.

“Everyone hates Big Pharma because it’s convenient,” said Peter Pitts, president and co-founder of the nonprofit Center for Medicine in the Public Interest and a former FDA senior communications and policy advisor. “They have to more aggressively, directly, and regularly communicate to the American public — and they’ve never developed a knack for it.”

Studies show what drug companies are up against. Research from the Institute for Public Relations and reputation management firm MAHA Global found that healthcare companies are among the most misunderstood in the world — and pharma, biotech, and healthcare firms ranked near the bottom in public perception across 16 industries.

“This result means that the general public consistently perceives players in the pharma/biotech/healthcare space more negatively than is deserved based on what these companies actually do day-to-day,” said Melissa Koski, head of insights at MAHA Global. “While their actions may be no different from those of companies with strong behavior scores, the public's perception of those actions is hard to overcome.”

So, what gives?

First, it’s complicated — starting with the fact that drugs are indeed more expensive in the US, although not necessarily because Americans are subsidizing lower prices abroad, as Trump has claimed. His Most Favored Nation policy, laid out in an executive order, would tie US drug prices to those paid by the country getting the lowest rate worldwide. But that’s not a straightforward solution, given that the US healthcare system is fundamentally different from those in Europe or Canada — making direct comparisons, let alone pricing parity, nearly impossible.

Drug pricing in the US isn’t determined by pharmaceutical companies alone. It’s the result of a layered system that includes drugmakers, insurers, pharmacy benefit managers (PBMs), wholesalers, and providers, each shaping how much patients ultimately pay.

“The president isn’t comparing apples to apples,” Pitts said. He noted that drug prices are lower abroad largely because governments negotiate directly with pharmaceutical companies through national healthcare programs. That comes with tradeoffs, including higher taxes and limits on which drugs are available — constraints Americans have repeatedly said they don’t want. “When the government sets the price, the government controls the choice,” he said.

That doesn’t mean affordability isn’t a problem. Kavita Patel and Kevin Schulman, both professors at Stanford University School of Medicine, note that overall pharmaceutical expenditures in the US rose 13.6% in 2023 to $722.5 billion. “This rapid growth in drug spending is unsustainable and threatens to jeopardize patient access to quality care,” they wrote.

According to a 2024 RAND study, US prescription drug prices are, on average, 2.78 times higher than in 33 other high-income countries in the OECD — a group of developed nations that work together on economic and social policy.

And Americans feel it. A recent poll by the Kaiser Family Foundation found that three in 10 adults report not taking their medication as prescribed due to cost.

Even with insurance, many Americans face significant out-of-pocket costs. Pitts pointed out that for most insured patients, affordability is more a function of coverage and co-pays than list prices. Generic drugs in the US are often cheaper than abroad, but newer therapies can leave patients with thousands in yearly costs.

JPA Health executive VP Tish Van Dyke called drug affordability a real issue and noted that, until the Affordable Care Act was enacted in 2010, many Americans didn’t even have access to negotiated drug prices. She added that pharma’s reputation problem is worsened by the public’s limited understanding of how the system works. “The science behind the medication is complicated, and the way you pay for it is complicated,” she said. “Most people don’t understand the patchwork that’s been put together for the last 80 years. And no one has the same way of paying for their healthcare.”

Asked why the industry takes the blame, she said, “I think it comes down to pharma companies because their name is on the product. But do they set the price? Not always. It’s the dealmaking between approval, marketing, and the place it ends up in someone’s medicine cabinet.”

Other communications leaders say pharma’s messaging challenge is heightened by today’s unpredictable policy environment. “There is a pressing need for clear and effective communication to help the public understand how policy changes affect them,” said Leslie Isenegger, who leads Real Chemistry’s public affairs practice. “Our clients need to bring an informed point of view to internal planning and public dialogue.”

She added that Real Chemistry encourages clients to share incremental updates and explain how policy shifts may affect specific patient populations or therapeutic areas. “That way, everyone on the front lines of communication — from corporate leaders to advocacy and medical affairs — is prepared to discuss both risks and solutions.”

Weber Shandwick’s Misty Fuller said companies also need to recognize the broader political environment. “Companies need a new playbook to respond, doubling down on the United States’ continued leadership in biopharmaceutical innovation and acknowledging that business as usual may not be the only way to achieve it.”

Some CEOs are flipping the MFN narrative, Isenegger notes. In a joint April 2025 Financial Times letter, the CEOs of Novartis and Sanofi argued that Europe’s pricing model is unsustainable and proposed a pan-European rate closer to US levels. PhRMA echoed the message, claiming “The US is not overpaying — Europe is underpaying.”

As Pitts put it, “It’s a question of healthcare fairness. What we really want is for the world to share equitably in the research and development.”

That R&D cost burden — much of it shouldered by US consumers and taxpayers — fuels tensions with foreign governments, particularly as NIH and university funding for basic research comes under political fire.

Still, Van Dyke urged the industry to keep perspective. “At the end of the day, it’s complex,” she said. “But for people dealing with childhood cancers, chronic illness or degenerative disease, this shouldn’t be a political football.

Photo courtesy of Nick Youngson