The Brink: Why are pharmacy chains closing disproportionately in low-income neighborhoods?

Cole Brahim: I think the first part of the question is why do pharmacies close? Often, it’s the whole retail store—Walgreens, CVS, Rite Aid—that shuts its doors because of financial struggles, which are in part due to increased competition. If a store or pharmacy isn’t bringing in enough revenue to cover costs, or if the store could do better elsewhere, it closes. This particularly affects retail stores in low-income neighborhoods, as customers have less money to spend and margins in these stores may be less favorable. Workforce is another factor: as pharmacists work longer hours, often with insufficient support, they may leave for a pharmacy or other job opportunity with higher pay or better support. This also contributes to pharmacy closures, where recruiting pharmacists to work in lower-income areas can be challenging, resulting in staffing shortages. Revenue shortfalls and workforce constraints end up shifting the limited number of pharmacies from lower- to higher-income neighborhoods, which in turn further exacerbates the health inequities that already exist.

The Brink: As a health services researcher, what is the long-term impact of a pharmacy closure in a low-income neighborhood, if there are no plans for another to open in its place?

Cole Brahim: The impacts of pharmacy closures in low-income neighborhoods are both immediate and long-lasting. Losing a pharmacy—which very well may be the only nearby pharmacy—means lack of access to critical medications, which in turn may mean more patients with uncontrolled chronic conditions, longer courses of illness, and sometimes serious or life-threatening complications. Even delayed access to medications can have serious health consequences. Patients may need to travel longer distances to pick up their medications, but lack of transportation, including not owning a vehicle or lack of reliable public transit, make it difficult to simply travel to a more distant pharmacy. And pharmacy closures don’t only impact access to prescription drugs. Oftentimes, it’s the whole retail location that closes, which means less access to over-the-counter medications, diapers, formula, food, toiletries—essential items that may be unavailable elsewhere. Pharmacies also offer vaccines and testing, so loss of a pharmacy also means loss of convenient access to these additional healthcare services. In the longer term, all of these factors will further widen racial/ethnic and income-related inequities in healthcare access and resulting inequities in health outcomes.

The Brink: What alternatives exist, especially for those on public health insurance like Medicaid?

Cole Brahim: If you need a prescription medication, there are some alternatives to going into a retail pharmacy. Some health plans, including some Medicaid-managed care plans, cover mail-order pharmacies for select medications, where medications may be delivered directly to your home, often as a three-month supply. However, not all medications can be delivered by mail. Coverage of multimonth refills through retail pharmacies also reduces the number of trips needed to the pharmacy, which may help if a pharmacy is no longer close by. However, this only works for maintenance medications with refills. Another more systemic alternative is increasing pharmacy locations in outpatient clinics and hospitals, so that medications may be picked up during healthcare visits. Expanding pharmacy availability at federally qualified health centers, which are located in low-income neighborhoods and are uniquely tailored to meet the social needs of diverse patient populations, may be particularly useful in combating retail pharmacy closures.

The Brink: What do you see as promising policy solutions to disrupt the nationwide trend of pharmacies struggling to remain profitable? 

Cole Brahim: First, we need policies that prevent the closure of pharmacies in low-income neighborhoods and in neighborhoods where persons disproportionately come from minoritized racial or ethnic groups. We also need incentives for pharmacies to open up in these same neighborhoods, if they don’t already exist. At a policy level, grant funded initiatives and tax incentives could be used to support and sustain pharmacies in designated low-income or underserved areas, which would effectively make it cheaper to operate a pharmacy in these locations. Another policy option is expanding the reimbursement of pharmacist delivered services, especially within Medicaid, which may especially benefit pharmacies in lower-income areas. But alongside these efforts, we also need alternatives to retail pharmacies that I mentioned, and we need to ensure alternatives are equitably available.