Spotlight Exclusives

Pharmacy Deserts Put The Health of Undeserved Communities at Risk

Dima Qato Dima Qato, posted on

Most of us may not think twice about the ease with which we can get a prescription filled. But for many Americans, particularly people of color, pharmacy access is becoming an increasingly dire problem, especially in low-income and underserved communities. A growing number of chain pharmacy closures  are part of the problem, but the bureaucratic maze of the pharmaceutical industry and Medicaid regulations also makes it more and more difficult for independent pharmacies to survive in the areas that most need them. Dima Qato, an associate professor at the University of Southern California and director of the USC Program on Medicines and Public Health, studies pharmacy access and health equity and spoke with Spotlight recently about the problem. The transcript of that conversation has been lightly edited for length and clarity.

Why don’t we start with your study on pharmacy deserts in urban areas?

Sure. Given that there are persistent disparities in access and adherence to prescription medications, we wanted to look to see if that’s because people don’t have access to pharmacies, because the majority of prescriptions are filled at retail community pharmacies. And we focused on urban areas because the majority of Black and Latinx populations live in large cities in the U.S.

Our first study focused on just Chicago, but the more recent study looked at the prevalence or disparities in pharmacy deserts in 30 cities. And what we found was a consistent, persistent pattern where majority Black and Latinx neighborhoods are less likely to have access to pharmacies than diverse and White neighborhoods. The magnitude of that difference varies—it’s worse in Chicago where a third of Black neighborhoods are pharmacy deserts as opposed to just 2% of White neighborhoods. But that disparity between communities of color and other communities is persistent across the country, and it’s gotten worse. It’s not just that these neighborhoods have to travel further to get to their nearest pharmacy, which is what a pharmacy desert neighborhood is, but with all these closures that are happening, the problem has become even more acute.

How do you define a pharmacy desert?

For urban areas, it’s one mile to the nearest pharmacy, unless you’re a low-income neighborhood where the majority of households don’t own a private vehicle, in which case it’s a half a mile.

And this trend of pharmacies closing is only making matters worse.

Pharmacies have been closing. Independent pharmacies are more likely to close than chains, but I think more recently in the last five years, what we’ve seen is that chains are closing as well. And I think what our data and research has shown is that chain or independent pharmacies, whenever they close, they’re more likely to close in low-income neighborhoods, neighborhoods that are predominantly or disproportionately publicly insured with Medicaid or Medicare, and Black and Latinx neighborhoods—the very same neighborhoods that are already pharmacy deserts. These closures will worsen and have worsened the problem of pharmacy deserts and disparities in pharmacy deserts across the country.

And what are some of the reasons that are being given for these closures?

For chains, underperforming, though it’s often unclear what that means. From our work, we know that many of the pharmacies that serve publicly insured or low-income populations don’t make as much money as pharmacies serving higher-income, privately insured neighborhoods. And that’s partly because they get paid less. A pharmacy that dispenses a prescription for Medicaid gets reimbursed less for that medication compared to a pharmacy that’s dispensing or filling a prescription for private insurance or commercial insurance. Theft is another reason that is brought up, but I think the key reason is it’s not profitable and these are businesses and at the end of the day, they need to make business decisions.

But for independents, there’s really a different story. Independents have found their market in these disproportionately Medicaid or low-income communities because they don’t have the competition that they would otherwise have in other neighborhoods. So, independent pharmacies are more likely to be located in these pharmacy desert neighborhoods, even though they’re also more likely to close. And when they close, the reasons are a little different. I think the reimbursement rates are still an issue for sure, but they also have to grapple with the regulations and policies for pharmacy benefit managers, contracts, preferred networks, all these kinds of health system factors that make it so hard for independent pharmacies to basically stay open. They’re willing to serve an underserved neighborhood, but they’re just not making a lot of money. It’s hard for them to even stay open in terms of operational costs and financial viability.

And if a majority or a big percentage of their customers are on Medicaid, that’s an additional administrative burden.

Exactly. It becomes very difficult for them to survive in the current climate of preferred pharmacy networks. Independent pharmacies are two times more likely to close than any chain, but they’re also more likely to open. They’re trying to open more stores. But they’re always closing because of all these different practices that make it really hard in this policy environment to make a profit.

And what about prescriptions by mail? Is that less of an option for these sorts of communities for various reasons?

It’s an option, just like everyone else has that as an option. But it may not be as feasible given housing stability or security. I think at the end of the day, most prescriptions are filled at retail pharmacies. And it’s not a solution if a pharmacy is not just a dispenser of medications, but a provider of services like vaccination, or when there’s an emergent need for contraception or Naloxone for opioid overdose. You can’t wait it for it to be mailed. I think mail is an option for everyone, but it may not be a feasible option for everyone nor is it practical to address the needs of these communities.

And has there been work done tying health impacts to being in a pharmacy desert?

There are several studies, including some that we’ve done, and we found a few things. One, people living in pharmacy deserts are more likely to stop taking their medication, older adults especially. Our study focused on older adults on cardiovascular drugs. We’ve also found that pharmacy deserts are associated with lower COVID vaccination rates. Something like three-quarters of COVID vaccines were administered at pharmacies.

There’s also some work that we’ve done around contraception where neighborhoods that have the highest unintended pregnancy or teen birth rates are for the most part neighborhoods that are pharmacy deserts. We’re trying to expand pharmacists prescribing over-the-counter contraceptive access but what does that mean to someone that doesn’t have convenient access to a local pharmacy. These policies really disproportionately benefit people that don’t need them as much and really don’t have that same benefit to those who do.

In terms of potential solutions, is there anything happening in California or in other states?

There are some potential policy-level solutions and I think some of them are around the obvious. We need to increase reimbursement rates for pharmacies serving Medicaid and Medicare patients. We need to improve the regulation of pharmacy benefit managers, so they don’t do these practices where they overcharge or exclude certain pharmacies from their network of pharmacies. Independents should be included—open pharmacy networks versus closing them is what that would mean, where you should be able to go where you want to go and not be forced to go to certain pharmacies of which many could be far away, especially if you live in a pharmacy desert.

And I think expanding 340B prescription drug programs to include independent pharmacies, especially those in low-income neighborhoods, may encourage pharmacies to stay open because there’s some profits that are to be made from 340B prescriptions. There have to be financial incentives for pharmacies to open and stay open. And aside from just increases in pharmacy reimbursement rates, I think leveraging federal funding for community health centers, which are often serve underserved areas that are often pharmacy deserts. The mass majority don’t even have an onsite pharmacy.

And is there movement on any of these issues in Congress?

I think the main movement right now is around PBM regulations and ensuring equitable and transparent practices around reimbursement payment and networks. I believe there’s also some legislation to try to ensure what are called essential retail pharmacies are part of pharmacy networks. But the problem with that legislation is that it’s not focused on neighborhoods or even cities, frankly, it’s for what they call service areas for health plans, which could be a whole county, a state, or even a region comprised of multiple counties or states.

And you are doing some new work that is looking more at the rural setting for this issue?

Right now, there’s two key projects we’re working on. One is looking nationally at urban, suburban, and rural, so not just rural, and it’s in partnership with the National Community Pharmacy Association. Another is looking at structural racism within Medicare Part D, specifically around pharmacy closures.

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