By Zachary Klemm, JHBL Staff Member
Introduction
Outrage and concern over the recent closure of a Walgreens pharmacy in Roxbury, MA—the fourth local Walgreens to close since 2022—permeates throughout that Boston community.[1] In response, Reverend Miniard Culpepper questions how the area’s seniors and single parents will access medications since they cannot travel far, noting, “it’s insensitive – it’s unjust.”[2] Culpepper and others organized a protest, serving as a voice for the predominantly Black, low-income area forced to grapple with the effects of yet another devastating pharmacy closure.[3]
Pharmacies and pharmacists play a critical role in dispensing crucial medications, administering vaccines, and educating patients.[4] Distinct from the doctor-patient relationship, patients do not need to schedule an appointment to speak with a pharmacist; the accessibility of a pharmacy allows patients to visit at their convenience.[5] In affluent American communities, pharmacy access does not pose an obstacle to those seeking to utilize pharmacy services.[6] Yet, many minority and low-income individuals living in marginalized communities are currently experiencing the devastating effects of a growing public health crisis: pharmacy deserts.[7]
The Food and Drug Administration (“FDA”) regulates brand-name and generic prescription drugs and non-prescription drugs.[8] The FDA also enforces federal laws such as the Food, Drug, and Cosmetic Act, which provides the agency with authority to oversee the safety of drugs, food, and cosmetics.[9] While the FDA possesses broad regulatory power in reviewing and approving medications, community pharmacies of various forms dispense drugs.[10] Like any business, privately owned drugstores can close or relocate at any time, and the government cannot force a pharmacy to remain open to guarantee access to medications. While federal and state governments should take other steps to remedy the effects of drugstore closures, pharmacy deserts pose a unique challenge because they are widespread and result from several unique factors.
Background
The term “pharmacy desert” refers to a physical area where, due to a lack of drugstores, individuals face barriers that impede their access to medications, vaccines, and pharmacy services.[11] Around one in four neighborhoods in the U.S. qualify as pharmacy deserts.[12] A rural area is a pharmacy desert if the nearest drugstore is over five miles away, and an urban area is a pharmacy desert if the nearest drugstore is half a mile away.[13] Pharmacy deserts pose a significant risk to the health of local residents, typically minorities of lower socioeconomic status.[14] The intersection between wealth and the higher prevalence of chronic health conditions in minority populations highlights the implications of depriving pharmacy access of the most vulnerable.[15] As pharmacies close locations in predominantly Black and Latinx communities and open locations in White neighborhoods, existing racial and economic disparities in health outcomes will worsen.[16]
Many factors drive pharmacies, including CVS and Walgreens, to close.[17] Walmart and large chain stores, along with online retailers such as Amazon, continue to broaden their pharmacy programs and offer cheaper medications in direct competition with traditional drugstores.[18] Brick-and-mortar pharmacies are also struggling financially due to theft, which is disproportionately higher in low-income communities.[19] Receiving lower reimbursements for prescription medications, recovering from the COVID-19 pandemic, and paying large lawsuit settlements in connection with the opioid crisis also negatively affects the financial health of drugstores.[20]
Pharmacy closures in disadvantaged communities force residents to travel farther distances for various medical needs, disincentivizing them and making it impossible to obtain necessary drugs and receive medical care.[21] Many elderly individuals lack easy access to public transportation and do not drive, and younger community members may not own a car due to economic factors, making travel to the nearest pharmacy challenging and time-consuming.[22] As a result, individuals, many who are older adults, do not receive the drugs they need to survive.[23] As an illustration of the negative consequences of pharmacy closures, one study found a difference in adherence to cardiovascular medication regimens between older individuals receiving medication from a pharmacy that subsequently closed, and individuals receiving medication from a pharmacy that remained open.[24] Individuals with a prior medication adherence rate of 80% in the group receiving a cardiovascular medication from the pharmacy that closed experienced an immediate decline in adherence of around 8.5% compared to those with consistent pharmacy access.[25]
Analysis
Developing policies and practices aimed at preventing pharmacy closures will combat the widespread effects of a lack of health services in affected communities.[26] Instituting polices that guarantee appropriate reimbursement of drugstores for prescription drugs may deter pharmacies from closing.[27] Left stranded with limited pharmacy access, individuals could order prescriptions from Amazon and other prescription delivery companies, but not all medications qualify for shipping and vaccine administration requires an in-person visit.[28] Independent pharmacies may broaden access to medications, but they are often not covered by insurance and are more likely to close first due to competition from chains.[29] Providing those residing in pharmacy deserts—like the elderly and Medicaid recipients—with transportation to nearby pharmacies would ensure that individuals obtain needed medications.[30] On the state and local government level, representatives should collaborate with community advocates and pharmacies to create sustainable methods of providing drugs and other health services to residents. The U.S. should devote more attention and resources to the health of its society, particularly those most vulnerable to adverse health outcomes. Crises such as pharmacy deserts shed light on the pervasive effects of unaddressed discriminatory practices in healthcare and society at large.
Disclaimer: The views expressed in this blog are the views of the author alone and do not represent the views of JHBL or Suffolk University Law School.
Klemm Blog PictureZachary is a second-year law student at Suffolk University Law School pursuing a concentration in health and biomedical law. He is interested in health law and medical malpractice defense. Zachary received his bachelor’s degree in English from Bates College in 2021.
[1] See Tiffany Chan, We Think it’s Insensitive: Residents Outraged as Walgreens Plans to Close Roxbury Pharmacy, cbs news (Jan. 11, 2024, 5:26 AM), https://www.cbsnews.com/boston/news/walgreens-closes-pharmacy-roxbury-black-neighborhood/ [https://perma.cc/4B95-CQK6].
[2] See id.
[3] See id.
[4] See Aaron Gregg & Jaclyn Peiser, Drugstore Closures Are Leaving Millions Without Easy Access to a Pharmacy, wash. post (Oct. 22, 2023, 8:00 AM), https://www.washingtonpost.com/business/2023/10/22/drugstore-close-pharmacy-deserts/ [https://perma.cc/JTG3-V6KQ]. Pharmacists are often the most accessible health care professionals in rural or low-income communities, meaning that pharmacy closures further limit healthcare accessibility in areas where medical resources are already scant. See id.
[5] See Danielle Wiener-Bronner, Drugstore Closures Could Make Pharmacy Deserts Even Worse, cnn (Nov. 6, 2023, 10:05 AM), https://www.cnn.com/2023/11/06/business/drugstore-closures-pharmacy-deserts/index.html [https://perma.cc/WK7D-MWWZ].
[6] See Gregg & Peiser, supra note 4.
[7] See id.
[8] See What Does FDA Regulate? u.s. food & drug admin. (June 1, 2020), https://www.fda.gov/about-fda/fda-basics/what-does-fda-regulate [https://perma.cc/H9DF-989J].
[9] See 21 U.S.C. §§ 351–360fff-8 (2002).
[10] See Teresa M. Salgado, et al., Primary Healthcare Policy and Vision for Community Pharmacy and Pharmacists in the United States, nat’l libr. med. (Sept. 18, 2020), https://www.pharmacypractice.org/index.php/pp/article/view/2160 [https://perma.cc/5CCC-ZDMP]. The community pharmacy model in the U.S. includes various sub-types, such as chain, independently owned, and supermarket pharmacies. Id. at 3.
[11] See Benjamin Y. Urick, et al., State Telepharmacy Policies and Pharmacy Deserts, jama network (Aug. 14, 2023), https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808246 [https://perma.cc/XMD6-TWC7]. “Pharmacy desert” derives from the FDA’s term “food desert,” geographical areas in the U.S. that lack stores which sell nutritious and affordable food. Id. See also Michele Ver Ploeg et al., Mapping Food Deserts in the United States, Econ. Rsch. Serv. U.S. Dep’t of Agric. (Dec. 1, 2011), https://www.ers.usda.gov/amber-waves/2011/december/data-feature-mapping-food-deserts-in-the-u-s/ [https://perma.cc/3QNH-4JDZ] (defining “food desert”).
[12] See Gregg & Peiser, supra note 4.
[13] See id.
[14] See Wiener-Bronner, supra note 5.
[15] See Poverty, Healthy People 2030, https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/poverty#cit9 [https://perma.cc/C7LK-FGMB]. “Barriers to accessing health care contribute to worse health outcomes for people with lower incomes.” See also Gopal K. Singh & Mohammad Siahpush, Widening Socioeconomic Inequalities in US Life Expectancy, 1980–2000, 35 Int’l J. of Epidemiology 969 (2006). Health inequalities continue to grow in the U.S. See id. Between 1980 and 2000, the life expectancy of members of higher socioeconomic groups increased more than groups with fewer economic resources. Id. See also Health Disparities, nat’l kidney found., https://www.kidney.org/advocacy/legislative-priorities/health-disparities [https://perma.cc/X6X7-Y9WC]. Compared to White individuals, the Black population in the U.S. is nearly four times more likely to develop kidney failure, and Latinos are 1.3 times more likely to develop the disease. Id. See also John Kevin Tucker, What’s Behind Racial Disparities in Kidney Disease?, Harv. Health Publ’g (Feb. 3, 2021), https://www.health.harvard.edu/blog/whats-behind-racial-disparities-in-kidney-disease-2021020321842 [https://perma.cc/NF4P-METW]. “These disparate health outcomes are indelibly linked to decades of social and economic injustice rooted in racism, the legacy of Jim Crow segregation laws, unfair housing laws, the redlining of communities of color, . . . and an unfair criminal justice system.” Id. See generally Pharmacy Deserts, Support the Pharmacy Desert Act of 2023, https://thepharmacydesertact.org/home, [https://perma.cc/R733-DJVZ].
[16] See Gregg & Peiser, supra note 4. Faced with an increased risk of high blood pressure and diabetes compared to other groups, access to medications and pharmacy services is imperative for racial minorities. See id. Pharmacy closures exacerbate ongoing health disparities by prohibiting those who are already more susceptible to disease from accessing crucial drugs. See id.
[17] See Wiener-Bronner, supra note 5. CVS shut 244 stores between 2018 and 2020 and plans to close 900 more locations through this year. Id. Walgreens closed 200 stores in 2019 and plans to shut down 150 more. Id.
[18] See Gregg & Peiser, supra note 4.
[19] See Nathaniel Meyersohn, CVS, Walgreens and Rite Aid Are Closing Thousands of Stores. Here’s Why, cnn bus. (Oct. 17, 2023, 1:49 PM), https://www.cnn.com/2023/10/18/business/rite-aid-store-closings/index.html [https://perma.cc/3PCF-WRK2]. “Theft appears to be hitting drug retailers more than other categories.” Id.
[20] See Neal Riley, These Rite Aid Stores in Massachusetts and New Hampshire Are Set to Close After Bankruptcy Filing, cbs news (Oct. 18, 2023, 12:18 PM), https://www.cbsnews.com/boston/news/rite-aid-store-closing-list-massachusetts-new-hampshire-bankruptcy/ [https://perma.cc/5NZW-YR99] (noting that Rite Aid plans to close stores in MA, NH, and CT). See also Parija Kavilanz, Rite Aid is Closing Nearly 100 Stores, With More to Follow, as Part of its Bankruptcy. See the List, Cnn Bus. (Oct. 19, 2023, 11:50 AM), https://www.cnn.com/2023/10/18/business/rite-aid-store-closings/index.html [https://perma.cc/7Z9D-FYHT]. Rite Aid filed for bankruptcy in October 2023, announcing that it would close 100 stores, and recently announced additional store closures. Id. See also Rite Aid Files for Bankruptcy Amid Opioid-Related Lawsuits and Falling Sales, cbs news (Oct. 16, 2023, 8:15 PM), https://www.cbsnews.com/news/rite-aid-bankruptcy-opioids-lawsuits/ [https://perma.cc/9L4K-CKKE]. In 2022, Rite Aid paid $30 million to settle lawsuits for its role in contributing to the opioid epidemic. Id.
[21] See Wiener-Bronner, supra note 5.
[22] See Medication Pick-Up and Other Services: Why They’re Crucial for Homebound Elderly, inst. on aging, https://www.ioaging.org/home-care/medication-pick-up-and-other-services-why-theyre-crucial-for-homebound-elderly/ [https://perma.cc/JRF8-43GG]. See also Wiener-Bronner, supra note 5. Pharmacy closures force a high concentration of residents to travel to nearby pharmacies, placing pressure on these businesses and increasing wait times for medications. See id.
[23] See Meyersohn, supra note 19. See also Ali Rogin & Kaisha Young, What’s Causing the Unusually High Number of Drug Shortages in the U.S., Pbs News (Nov. 5, 2023, 5:35 PM), https://www.pbs.org/newshour/show/whats-causing-the-unusually-high-number-of-drug-shortages-in-the-u-s [https://perma.cc/JSU8-RUFQ]. Recent prescription and over-the-counter drug shortages also pose a significant obstacle, preventing individuals from receiving their medications even if they can access a pharmacy. See id.
[24] See Dima M. Qato, et al., Association Between Pharmacy Closures and Adherence to Cardiovascular Medications Among Older US Adults, JAMA Network (Apr. 19, 2019), 10.1001/jamanetworkopen.2019.2606 [https://perma.cc/Q5JY-5YJ4].
[25] See id.
[26] See Elaine O. Nsoesie, Pharmacy Deserts in Black and Latino Communities Are Harming Residents; There is No Lack of Evidence on Who is Impacted by Pharmacy Closures, but it’s Unclear What Solutions Cities Like Boston are Developing to Prevent Future Closures, Bos. Globe (Jan. 18, 2024, 3:00 AM), https://www.bostonglobe.com/2024/01/18/opinion/walgreens-closures-pharmacy-deserts-black-latino-roxbury/ [https://perma.cc/7JQX-VD4X].
[27] See id.
[28] See Wiener-Bronner, supra note 5.
[29] See id.
[30] See Nsoesie, supra note 26.