Rural Communities Losing Their Pharmacies and the

Prohibitive Pricing of Necessary Medication

By Thomas Coffin

Kaiser Health News recently published an article titled The Last Drugstore – How Rural Communities Are Losing Their Pharmacies.

Perhaps ominously, the very month that this article appeared (November 2021) the BiMart pharmacy in Creswell, Oregon, where my family has been obtaining our prescription medication for decades, abruptly closed with no advance warning to its patients. (It is no exaggeration to describe them as “patients” because pharmacies are the dispensers of the medication that their physicians have determined are necessary for their health.)

I had arrived at the pharmacy soon after opening time on a Saturday morning to pick up a blood thinner medication, Eliquis, prescribed by my physician to reduce my risk for clots and a stroke. The prescription had been phoned in, and I was informed by my physician’s office that it might take several days for my insurance coverage to authorize it as it was an expensive drug.

After allowing sufficient time for that authorization, I went to BiMart only to find the pharmacy section shuttered and a “closed” sign prominently displayed in the waiting area. There were several employees whom I took to be pharmacy technicians seated in the area looking despondent, and I was met by a person in a suit who appeared to be a BiMart manager who informed me the pharmacy was no longer in operation. I responded that my doctor had submitted my prescription days earlier and that it was critical medication which was necessary given my condition. To my dismay, I learned that the prescription had not been filled, nor had I been informed beforehand that the order by my physician would not be provided at this pharmacy. When I inquired about how to go about obtaining my medication, I received a shrug and was told I should have the prescription re-ordered from another pharmacy.

I share this tale because I am confident that I was not the only person confronted with this sudden blockage to medication that, frankly, is time sensitive and can often be considered as “urgent” depending on the patient’s medical condition.

This personal experience motivated me to do my own research into what appears to be an unfortunately escalating scenario with foreboding impacts on those seniors living in rural areas. The Kaiser News article referenced above was my starting point. What follows is more information that hopefully will be of use to those of us who depend on our local pharmacies as well as give us better insight into the pharmaceutical drug industry in the United States. It can only help to understand the Beast that threatens our access to the medical care and medication we need and, in all justice, we should easily have at a fraction of the cost which consumes so much of our fixed incomes. Hopefully, what I have learned can be shared not only with our senior citizens but everyone navigating the medical provider system here in the United States, as contrasted with those countries which embrace universal health coverage for its people.

Let me continue by discussing pricing issues within the pharmaceutical companies.

Take Eliquis, my prescription. Bristol-Meyers Squibb developed and owns the patent for the drug. Patent protection can last for decades, and the patent protection against competition can last for decades. The patent for Eliquis isn’t set to expire until 2031. When a pharmaceutical corporation owns the patent for a drug, it is basically free to set whatever price it wants for the medication because it has no competition for the product. In fact, Bristol-Meyers has reportedly filed lawsuits against companies that have initiated production of generic Eliquis. (See Why Is Eliquis So Expensive?)

The data I have discovered is that the average cost to the consumer of a month’s supply of Eliquis (60 tablets) is $556. The amount covered by insurance (if any) will vary per individual. My insurance leaves me with a co-payment of $200 per month. In scanning the international market, I have discovered prices as low as $1/pill or $60 for a month’s supply, roughly 10% of the USA price. Interestingly, the $1 pill sold in Turkey is manufactured at a Bristol-Meyers facility located in Puerto Rico, in USA territory. (See PharmacyChecker.) Data on recent sales of Eliquis around the world reflects that they sold $9.7 billion in 2020, a 16% increase over 2019. (See FiercePharma: Eliquis.)

While I am unable to find data on the actual cost of manufacturing per pill (often that is a protected trade secret), one can assume that cost is less than the $1 bargain being offered overseas.

Moving on from the pricing itself, which obviously has a seismic impact on the consumer, we need to be aware that it also has a negative effect on our local pharmacies (especially those in rural areas). This gets us to the question of why BiMart and other pharmacies are closing.

BiMart, according to its website, is an employee-owned corporation. That being said, I confess to being perplexed at what seemed to be an unfortunate abruptness in its closure, not only for its clients but also for its employees. That aside, the company’s announcement when it sold its pharmaceutical operation to Walgreen’s mega nationwide chain was undoubtedly very accurate—the profit margin in providing that service was too small to justify its continuance.

That is the hard reality of our health care system as it exists today—the pharmacies are the ultimate dispensers of the medications and must hire the pharmacists with their professional expertise to fill the prescriptions and consult with the recipients regarding its usage, possible side effects, contraindications, etc. As the population ages, the demand for medications increases as does the need for more pharmacists. But the higher the cost of the pills as set by the manufacturer, the combination tends to shrink the pharmacy’s profit margin, as do claw back audits by insurance companies resulting in further losses of insurance reimbursements. Some pharmacies, as the Kaiser Health News reports, are left operating at a net loss. Beyond that, those pharmacists tasked with preparing the medication and consulting with the consumer are stretched to the point of exhaustion.

I have a close family member who is a pharmacist, and thus I am privy to a first-hand account of the difficulties of the profession as well as the knowledge and skill required of them. In rural communities especially, when pharmacies close, the demand on whatever pharmacies remain in the area increases as does the workload of the fewer pharmacists who must put in longer hours to fill the additional prescriptions. This is a vicious cycle, crying for a solution.

So, what is the solution? Here are some of my thoughts, which I hope will spark awareness among those affected by these important healthcare issues and result in a dialogue about a path to correct the imbalances and inequities in the existent environment of a profit-driven medical care system.

First, those of us who are in need of prescription medications should refrain from venting our anger at the pharmacists who prepare and deliver the medications prescribed by their physicians. The prices are not set by the pharmacists, who have no control over the economic factor including the amount (if any) which is covered by insurance.

Second, please understand that these providers are responders to your medical needs, and are valuable resources to help you with your medical needs. They may not be in the category of first responders like paramedics, police, firefighters, and ER personnel, but they are latter tier responders and we should be grateful for their service on our behalf.

Third, those of us who are seniors are a potent voting bloc. Use your influence as a group with local, regional, state, and federal representatives to lobby for meaningful reformation of the laws that regulate the healthcare industry and particularly pharmaceutical giants like Bristol-Meyers in the patenting and price-setting of medication that is vital to your health and even life itself. On the local level, insist on advance notice of the specific date on which your area pharmacy plans to close to allow you time to coordinate with your insurance carrier and healthcare providers for the transition.

Fourth, open your mind to health care systems in other Western democracies such as Canada and Britain where universal health coverage is freely available and funded, just as our Social Security and Medicare benefits are, through taxpayer contributions. The trite canard that such government programs amount to “Socialism” or the ultimate bogeyman “Communism” is garbage rhetoric designed to make you ignore the fact that our very own Constitution, as expressed in its Preamble defining the purposes of the democratic government being established, includes as one of its main purposes to “promote the general Welfare.” When it is common news that the most wealthy billionaires in American society pay little or even no taxes, it is only just to require them to contribute a fair share of their helping of the nation’s economic pie to promote the general Welfare of the People enriching them. (Just ponder the $9.7 billion in profits reaped in one year by one corporation by just one of the drugs you bought.)

Finally, I would cite the noble example provided us by the son of Ashkenazi Jewish parents who emigrated to this country in order to escape persecution in their native homeland. I speak of Dr. Jonas Salk, who invented the polio vaccine that successfully eradicated the crippling and deadly viral polio scourge ravaging the world in the 1940s and 1950s era. Dr. Salk could have made an incredible fortune had he obtained a patent for his vaccine, but instead he chose not to patent it or seek any profit from marketing it in order to maximize its global distribution. When he was once asked “who owns the patent to the polio vaccine,” he responded “the people own it.”

We need that spirit, compassion, and willingness to serve humanity today. We need leaders who sow cooperation, not conflict, working together, not against one another, sharing our gifts, not just hoarding and enriching only ourselves with our talents. Societies which embrace altruism survive while those which lack it shrivel and self-destruct. I have the utmost admiration for the Jonas Salks among us, and very little or none for those who cannot see beyond their own self-interests.

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Thomas Coffin was the keynote speaker at the Blackberry Pie Society’s Political Party in February, 2020. He is a retired federal magistrate judge for the U.S. District Court for the District of Oregon and a former professor at the UO Law School. Thomas retired in 2016 after 24 years on the bench, prior to which he had a career as a federal prosecutor spanning 21 years. He is married with 7 children. The Blackberry Pie Society is pleased to include a collection of his essays on our website. We will post them as they become available.

posted 01.20.2022