We declared pharmacies essential and let them fail. A Walgreens in a Chicago neighbourhood shuts down. A CVS store in New York closes. A Rite Aid store shutters in a small Midwest town. The same thing is said about each closure. Things are changing in retail. Margins are small. People's shopping habits are changing.

This explanation has been repeated so many times that it now sounds like a script. It assumes that the public will not see the pattern, or worse, that the pattern does not matter.

According to research summarised by Health Affairs at UC Berkeley, over one in three retail pharmacies in the United States has closed in the last decade [1], [2]. For years, new businesses opened as fast as old ones closed. That balance came to an end in 2018, when pharmacy closures began to outnumber new openings for the first time in more than a decade [1], [3].

Between 2018 and 2021, 41 states lost more pharmacies than they gained, affecting more than 91 million people [1], [2]. It is easy to describe this as a retail trend, but that framing avoids calling it what it is: a healthcare access failure that policymakers have watched unfold and chosen not to interrupt.

How Pharmacies Became the Front Door to Care

Pharmacies became the primary means of accessing care because the rest of the system had become difficult to use. A sweeping policy vision did not elevate pharmacies into this role. Primary care requires appointments. Clinics operate within limited hours. Provider shortages are treated as background conditions rather than design failures. Pharmacies filled the gap because they were open, local, and did not require permission to enter.

Associated Press reporting shows how this plays out in real life. Pharmacists describe being the first stop for sick children, patients managing chronic illness, and people unable to access timely care elsewhere [4]. In many rural towns and low-income urban neighbourhoods, the pharmacy is not a convenience: it is the only consistently accessible point of care.

Eventually, policy followed practice, and states expanded pharmacists' scope of practice. Pharmacies began administering vaccines, managing chronic disease counselling, dispensing HIV prevention medications, and, in some cases, prescribing therapy directly. Researchers at UC Berkeley note the irony clearly. As policymakers expanded the services that pharmacies were allowed to provide, the number of pharmacies capable of delivering those services declined [2].

This was not an unforeseen outcome. The system was built with this contradiction embedded within it.

Pharmacy Closures Follow Predictable Lines

Closures do not occur randomly. Independent pharmacies are more than twice as likely to close as chain stores. They are far more likely to be located in Black, Latinx, rural, and low-income communities [1]–[3]. Health Affairs researchers found closure rates of 37.5% in predominantly Black neighbourhoods and 35.6% in predominantly Latinx neighbourhoods, compared with 27.7% in predominantly white neighbourhoods [1].

The Health Affairs Scholar analysis of pharmacy deserts strengthens this pattern. Using national data, the study finds that pharmacy deserts disproportionately affect communities with higher proportions of racial and ethnic minorities, Medicaid beneficiaries, people with disabilities, and individuals with limited English proficiency [5]. Over 15 million Americans live in census tracts with either no pharmacy access or severely restricted access [5].

Associated Press analyses of state licensing data confirm the same trend. Neighbourhoods that are majority Black or Latinx have fewer pharmacies per capita, even before recent closures are taken into account [4].

Rural areas face even steeper consequences. Cornell policy experts warn that pharmacy closures will disproportionately harm rural and inner-city Americans, where replacement options often do not exist at all [6]. Walgreens alone plans to close more than 1,200 stores over three years, a number large enough to reshape access across entire regions [6]. When a pharmacy closes in a wealthy neighbourhood, inconvenience follows. When one closes in a rural town or an underserved urban area, access to essential services collapses. Treating these outcomes as equivalent obscures real harm.

Pharmacies Were Not Made Fragile by Accident

Retail pressures are real. CNBC documents declining prescription reimbursement, inflation, theft, worker burnout, and competition from online retailers as major stressors for chains like CVS and Walgreens [7]. Walgreens executives themselves have acknowledged that the current retail pharmacy model is under strain [7]. But retail explanations function as euphemisms. They obscure the policy mechanics that determine which pharmacies survive.

Health Affairs researchers identify exclusion from preferred pharmacy networks controlled by pharmacy benefit managers (PBMs) as a major driver of closure risk [1]. Independent pharmacies are often excluded from these networks, which steer patient volume through lower cost-sharing and contractual preference. Consolidation between PBMs and large pharmacy chains has further depressed reimbursement rates for independent pharmacies and rival chains alike [1], [3].

The Health Affairs Scholar paper reinforces this point, showing that pharmacy churn is not merely an economic phenomenon but a policy-mediated one, shaped by contracting practices, vertical integration, and reimbursement design [5]. Calling this a market outcome is convenient. It is more accurate to describe it as a policy choice enforced through contracts most patients never see.

Exit is also effortless. A PLOS ONE analysis notes that there are no meaningful federal requirements governing pharmacy closures beyond administrative steps such as license termination and record handling [8]. Large chains can close pharmacies with minimal obligation to assess community impact or ensure continuity of care.

The message is consistent. Pharmacies are encouraged to expand services, absorb risk, and accept shrinking margins. When sustainability fails, they are expected to leave quietly.

What Disappears When a Pharmacy Closes

When policymakers discuss pharmacy closures, the focus often narrows to distance. How far must someone travel now?

Distance matters. People living in medically underserved areas already travel farther to reach pharmacies, and closures significantly widen that gap. Increased travel distance is associated with worse medication adherence and higher downstream costs [8].

But geography is not the main loss. MedShadow reporting describes pharmacies as community anchors. Pharmacists prevent medication errors, identify changes in patient behaviour, and build trust over time [9]. That trust does not transfer to mail order delivery or a distant chain location.

Associated Press reporting highlights another overlooked consequence. Pharmacy staff often speak the dominant language of the community and reflect the populations they serve. When these pharmacies close, patients are told to go elsewhere, as if care were interchangeable and relationships disposable [4].

The Health Affairs Scholar analysis warns that expanding pharmacy services without protecting physical access points risks worsening inequity. Improvements in convenience primarily benefit affluent populations, while high-need communities often lose access to care altogether [5]. This is not an accident. It is the predictable result of how access has been designed.

The Access Story No Longer Holds

Policymakers understand the contradiction at the center of pharmacy access debates. They simply avoid owning it. Access is treated as a moral entitlement, while the conditions required to sustain access are treated as optional.

Pharmacies are declared essential. Their responsibilities expand. They are relied upon to compensate for failures elsewhere in the healthcare system. At the same time, reimbursement is allowed to fall, networks are allowed to exclude them, and closures proceed with minimal scrutiny.

When pharmacies shut down, public frustration is directed at corporations. Exit is framed as abandonment. But exit is not a moral failure. It is a rational response to incentives.

An expert quoted by the Associated Press argues that if healthcare is a right, pharmacies should not be able to close after filing paperwork and posting a notice on the door [4]. The instinct is emotionally satisfying. But simply preventing closures avoids the harder work of fixing the policies and incentives that made those closures inevitable. 

Permanence cannot be declared. It must be built.

What a Credible Policy Response Would Require

A credible response would stop pretending the problem is vague and address the mechanics directly. First, preferred pharmacy networks require oversight. Health Affairs researchers recommend increasing independent pharmacy participation in preferred networks and limiting arrangements that disproportionately favour chains, particularly those under common ownership [1].

Second, payment must reflect expectations. If pharmacies are expected to deliver preventive care, chronic disease management, and public health services, reimbursement must support that role. Targeted increases in Medicare Part D and Medicaid reimbursement for pharmacies serving or at risk of becoming pharmacy deserts are explicitly recommended [1], [5].

Third, closure should not be frictionless. The PLOS ONE analysis advocates for increased oversight and meaningful community engagement before pharmacy closures, particularly when closures disproportionately affect access [8].

None of this requires turning pharmacies into public utilities. It requires aligning responsibility with sustainability.

Why This Matters Beyond Pharmacies

Pharmacy closures expose a deeper habit in US health policy. Aspirational language substitutes for institutional design. Access does not exist because it is declared. It exists because people are allowed to serve others sustainably, bear responsibility, and participate in voluntary exchanges that endure over time.

If the system cannot keep pharmacies open in the communities that rely on them most, promises about expanding access elsewhere should be treated with skepticism. Until incentives change, taped notices on glass doors will remain the most honest access policy many communities have ever received.