Since the early days of American medicine, pharmacies have played an indispensable role in assuring the health of local communities. As trusted local advisors, pharmacists have served as a key access point to vital medications, tests, urgent care, and medical advice for those in their community. With the introduction of the COVID-19 vaccines and the provision of Paxlovid, this role has expanded to pandemic prevention and preparedness. As COVID vaccine administration efforts gathered steam, pharmacies became the single most important access point across the country, ultimately culminating in more than 258 million doses of COVID-19 vaccines having been administered by pharmacies in the U.S.
Despite their importance, we continue to see significant disparities in access to pharmacies in this country. As physicians, we try our best to work with patients to ensure they have access to their medications and often ask questions like “which pharmacy is closest to you” or “which pharmacy do you prefer.” However, despite our best efforts, studies show only 72 percent of new medications are picked up by patients. While there are many barriers to accessing medications — such as cost, navigating insurance, and healthcare literacy — in our recent work, we focused on the logistics of physically getting to a pharmacy.
Pharmacy deserts, a term initially borrowed from the FDA’s “food deserts,” are areas in which access to pharmacies is limited by geography, resulting in challenges accessing the vital medicine and medical care pharmacies provide. These sorts of areas are unfortunately rampant across the United States. As many as one in three neighborhoods in our largest cities are in a pharmacy desert, and they disproportionally impact racial/ethnic minorities.
While these important prior studies focused on the physical distance from a patient’s home to the closest pharmacy, in a recent paper, we utilized open-source tools to estimate the real-world travel time. For example, when thinking about which grocery store is most convenient or accessible, we generally think of the time it takes to get there rather than the distance. This preference is even more apparent in urban settings where distance and time can be very poorly correlated (i.e. short distances might take long times because of high density road networks, traffic patterns, and public transit routes).
In our study of over 4,500 neighborhoods in the four largest U.S. cities, we found that when taking travel time into consideration — by car and public transit — half a million people lived in pharmacy deserts. In all four cities, these deserts were much more likely to occur in predominantly Black and Latino neighborhoods. In cities with robust public transit (NYC, Chicago), public transit pharmacy deserts are less common than car pharmacy deserts. Our findings brought home the need to think carefully about the meaning of equity and access when evaluating access to medical care. Although important, thinking about distance from point A to B only provides a part of the story.
More broadly, the notion of an access “desert” — used by various governmental agencies — is ripe for revision.
While absolute distance to a location can be a helpful way of starting a conversation about access, we believe that these definitions are incomplete if they do not include real world measures like travel time as a criterium.
Armed with our findings, we have begun to work carefully with patients to ensure that when we prescribe, our patients can get their medications easily. Some of these barriers can be overcome with home delivery, while others require careful planning with patients to make sure their chosen pharmacy is one they can access. Additionally, since pharmacy closures are more likely to happen in Black and Latino neighborhoods, and because independent pharmacies play an outsized role in these neighborhoods, some have suggested incentivizing pharmacies to open locations in desert neighborhoods by raising Medicare and Medicaid reimbursement and including pharmacies in federal programs that increase payments to primary care providers. Ultimately, we suspect that a combination of these strategies would ensure durable and equitable access to pharmacies for all of our patients.
Dr. Peter Kahn is a fellow in the Section of Pulmonary, Critical Care and Sleep Medicine at Yale School of Medicine. He graduated from the Albert Einstein College of Medicine with honors and his M.P.H. from the Johns Hopkins Bloomberg School of Public Health in the department of Health Policy and Management. Dr. Kahn’s research has focused on health policy with a particular interest in the impact of climate change and utilities on health policy. Follow him on Twitter @PeterKahnMD
Dr. Xiaohan Ying is a resident in the department of internal medicine at New York Presbyterian Hospital/Weill Cornell. He graduated from Wharton with a focus in Healthcare Management and Policy and received his MD from Weill Cornell Medicine. Dr. Ying previously worked as a healthcare consultant, and his research focuses on health disparities and health policy.
Dr. Stan Mathis is the medical director of an ACT team and assistant professor in Yale’s Department of Psychiatry. A background in architecture and urbanism informs his clinical and research/teaching work. Taking care of patients in their homes or in the community, he sees firsthand the impact of the extra-clinical environment on their lives and wellbeing. He also co-developed a curriculum that combines data-driven and experiential learning to help psychiatry residents develop a deeper understanding of New Haven and the forces, historical and current, that impact its population.