Originally published by STAT
By Anika Nayak
Pharmacies were once abundant in the South Side of Chicago. Now, residents living in the majority Black neighborhood often find themselves with few options when it’s time to get a prescription refilled or stock up on cold medicine.
Ladell Johnson, a longtime resident of the South Side, drives half an hour from her house to the downtown area every time she needs to pick up her prescription. “Luckily, this pharmacy is close to where I work, but my house is half an hour away by car or one hour by bus,” she said. “If I didn’t have a car, I would have to walk 20 blocks one way to my closest pharmacy.”
As pharmacies shutter stores across the U.S., people in low-income and predominantly Black, Latino, and Indigenous neighborhoods are increasingly left in pharmacy deserts, without easy access to medications and other essentials. In November 2021, CVS announced that it would be closing 300 stores a year across the country in the next three years, and Rite Aid, which filed for bankruptcy in October, plans to close at least 150 stores in the next several months.
“Pharmacy deserts have been a longstanding issue that has gotten worse with recent closures of both independent and chain pharmacies,” said Dima Qato, an associate professor at the University of Southern California School of Pharmacy, who studies disparities in geographic access to pharmacies and spent more than a decade working as a community pharmacist in Chicago. That lack of access can have major consequences for the health of people living in marginalized communities.
How pharmacy deserts impact people’s health
A 2021 study co-authored by Qato, published in Health Affairs, examined disparities in pharmacy access in major cities such as Los Angeles, Chicago, Houston and Memphis. In Los Angeles, one-third of all Black and Latino neighborhoods were pharmacy deserts — meaning that the average distance to the nearest pharmacy was 1 mile or more. The biggest racial gap in pharmacy access was in Chicago, where only 1% of white neighborhoods were pharmacy deserts, compared to 33% of Black neighborhoods in the South Side.
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Rural and suburban areas qualify as pharmacy deserts if the nearest drugstore is more than five or two miles away, respectively, Qato said. However, the radius drops to just half a mile in low-income neighborhoods with low vehicle ownership, as it can be hard for residents to walk or take public transportation to the nearest pharmacy.
“When pharmacies close, there’s some people who stop taking their medications — especially if they live in pharmacy deserts. Others may take time off work or delay picking up their prescriptions,” said Qato.
In an earlier study of 3 million adults, published in JAMA Network Open, Qato and her colleagues found that when pharmacies close in a community, older adults are more likely to stop getting their prescriptions filled for vital heart medications such as statins, beta-blockers, or oral anticoagulants.
Pharmacy deserts can take a particular toll on Black, Latino, low-income, and uninsured households because these groups are already at higher risk of chronic disease, said Juan Tapia-Mendoza, a community pediatrician who practices in Washington Heights in New York City. “Now it’s harder for them to access the prescription medications they rely on to treat common chronic diseases such as diabetes, heart disease, and arthritis.”
People living in pharmacy deserts also have more limited access to flu shots and vaccines for Covid-19. That’s a particular problem at a time when many community doctors and health facilities have not yet received the latest Covid vaccine, leaving patients in underserved areas with few alternatives, experts tell STAT. “Pharmacies were crucial in Covid vaccine rollout,” said Utibe Essien, an assistant professor of medicine and a health disparities researcher at the University of California, Los Angeles.
Pharmacy Deserts
Given longstanding vaccine hesitancy among Black and Latino communities, making immunizations even harder to access puts this already-vulnerable population at higher risk. “We’re talking about a community that has been historically terrorized by homeland security, immigration and customs enforcement, and the police. There’s already an inherent fear to seek medical help because they think that somehow the information they provide is going to be used against them,” said Tapia-Mendoza.
In the South Side, Johnson received her flu vaccine at her local church, which transformed into a mass vaccination clinic in collaboration with a health center. This site has been imperative to making vaccines accessible for people in her community, she said, so they don’t have to travel to a pharmacy.
Why pharmacies like CVS, Walgreens, and Rite Aid are closing stores
Often, the decision to close a chain pharmacy store is purely a business one — albeit without the effects on communities in mind, said Tapia-Mendoza. Rite Aid spokesperson Alicja Wojczyk told STAT in a statement that as part of its bankruptcy process, “we notified the Court of certain underperforming stores we are closing to further reduce rent expense and strengthen overall financial performance.”
Walgreens spokesperson Kris Lathan told STAT that the company takes several factors into account when closing locations, “including our existing footprint of stores, dynamics of the local market, and changes in the buying habits of our patients and customers.” Lathan also noted that Walgreens has partnered with local churches and civic groups to “offer off-site and mobile clinics in neighborhoods and rural areas where we’re able to provide walk-up access to life-saving immunizations.”
CVS declined to comment on how it makes decisions about store closures.
Independent pharmacies struggle to stay afloat
The problem of closures isn’t just limited to major retail pharmacy chains. A JAMA Internal Medicine study published by Qato and her colleagues found that one in eight pharmacies closed during the six-year period between 2009 and 2015. According to their analyses, independent pharmacies in both urban and rural areas were three times more likely to close than chain pharmacies.
“I’ve been in Washington Heights for 30 years and the pharmacists that served my patients practiced in the independent pharmacies,” said Tapia-Mendoza. Smaller, independent pharmacies started to go out of business when the big retail giants entered the community over the past 10 to 15 years, he noted.
Many health plans also steer people toward their “preferred” pharmacies where drugs are cheaper and copays are lower, Qato noted: “Independent pharmacies are often excluded from networks, which results in patients going to chains.”
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The majority of independent pharmacies’ earnings come from reimbursements they receive for filling prescriptions. Another issue, according to Qato, is that pharmacies at higher risk of being closed are those with a large customer base on public insurance like Medicare and Medicaid, which have lower reimbursement rates than private health plans. Compounding the problem is that pharmacy benefit managers often wind up under-paying pharmacies through low and delayed reimbursement rates.
“Due to the lack of PBM regulations, independent pharmacies are closing more in low-income communities of color, which we know are disproportionately publicly insured,” said Qato.
Independent pharmacies are also often excluded from the 340B drug pricing program, a federal program that requires manufacturers participating in Medicaid to sell drugs at substantial discounts to hospitals or clinics, experts told STAT. “These hospitals and clinics often contract with large chain pharmacies that charge payers non-discounted prices for prescriptions filled,” said Qato. “The revenue derived from the drug sales is then distributed to both the covered entities and 340B contract pharmacies.”
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Between 2006 and 2019, the number of contract pharmacies grew in affluent and predominantly white neighborhoods, and declined in socioeconomically disadvantaged and Black and Latino neighborhoods, according to a study in JAMA Health Forum. “We have preliminary data that suggests that 340B contract pharmacies are more protected from closure,” said Qato.
All this is particularly troubling because people who have been historically neglected by the U.S. health care system often trust independent pharmacies over bigger chains. “These pharmacists are from the community they serve and will employ staffers that are bilingual to deliver culturally competent care to our patients,” Tapia-Mendoza said.
When Johnson was growing up in the South Side of Chicago, she recalls going to a locally-owned pharmacy, where the pharmacist ended up becoming friends with her mother. “The pharmacist got to know her and took good care of her whenever she needed counseling or getting her prescription refilled,” she said. “It was so much easier to go to a pharmacy when there was a personal connection than nowadays where pharmacists don’t even explain anything.”
From mobile pharmacies to free over-the-counter drugs
The few pharmacies that do remain in the South Side are often overburdened and unable to keep up with demand. “I never visit my closest pharmacy because I never usually get my prescription filled on time or find any over-the-counter medications, since they’re all out of stock,” Johnson said.
Another common issue in pharmacy deserts is that the few that are available often operate under limited hours. “In Washington Heights, there’s only one pharmacy open past 9 o’clock at night. All of the other pharmacies close by 8 or 9 p.m.,” said Tapia-Mendoza. That’s a particular disadvantage for patients living in low-income communities and communities of color, who often work long hours or multiple jobs and may not be able to get their prescriptions filled promptly.
More efforts need to be made to encourage pharmacies to stay open in these communities, experts told STAT. Increasing Medicaid and Medicare pharmacy reimbursement rates for prescription medications might be a start, but policymakers also need to make sure that stores serving Black and Latino communities are not excluded from health plans’ pharmacy networks.
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“Both independent and chain pharmacies serving pharmacy desert neighborhoods within a plan’s service area should be included in the plan’s preferred pharmacy network,” said Qato. “Such regulations would ensure pharmacies serving disproportionately low-income, publicly insured populations are included in a plan’s preferred network and, in turn, these pharmacies — which are often the nearest pharmacies to pharmacy deserts and most at-risk for closure — can be used to fill prescriptions for the community.”
In the absence of typical brick-and-mortar pharmacies, other alternatives seek to meet patients where they are. In Connecticut, for example, Yale School of Medicine researchers have opened up the first mobile pharmacy in the state. The project, known as InMOTION, aims to bring care to people who are at risk of or living with infectious diseases, such as HIV, as well as those with substance use disorders, such as opioid use disorder.
“HIV treatment requires taking antiretroviral medications for life. People living with HIV may delay their medications if they don’t have access to reliable transportation or don’t have a walkable pharmacy nearby,” said Sandra Springer, leader of the InMOTION project and professor of medicine at Yale School of Medicine. InMOTION also partners with community health workers to identify people who do not have HIV and are eligible to receive pre-exposure prophylaxis (PrEP), which helps prevent the virus, said Springer.
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Connecticut is currently the only state in the U.S. where mobile retail pharmacies are legal. Springer and her colleagues worked with state legislators to pass a law allowing drugs to be dispensed in locations beyond their designated storefronts.
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In some parts of the country, community physicians like Bernadette Lim have taken matters into their own hands. Lim is the founder of Freedom Community Clinic in Oakland, California, an initiative that provides community–centered services free and/or at community scale to underserved communities in the Bay Area. To expand the clinic, she and her team are opening up a completely free pharmacy in spring 2024 with over-the-counter medications and contraceptives. “For a lot of people, there is not enough trusted information out there on medications,” she said. “In different grocery stores and retail pharmacies, Black and Brown people don’t find themselves safe or find medications accessible.”
Lim acknowledges that such measures won’t solve the larger issue of pharmacy deserts across the country. “People need pharmaceuticals, especially for very acute and chronic conditions. And if you have an interruption to that, then it literally then causes emergencies to happen.”
Ultimately, experts say, lack of access to a nearby pharmacy is a human rights issue. “When closing a pharmacy, it means closing an epicenter that provides access to lifesaving medications, contraceptives, and vaccines,” Qato said. “The mass closure of pharmacies fail vulnerable communities.”