We turned pharmacies into the backbone of public health during coronavirus disease 2019 (COVID-19). Then we went back to paying them like retail stores. The result is what I think of as the pharmacy paradox. We expanded their role without changing the economics that sustain them. Now, across the country, those same pharmacies are closing, quietly and disproportionately in the communities that need them most.

In 2021, the corner drugstore ceased to be simply a place to buy shampoo, gum, and blood pressure refills, and became a civic utility: a vaccination and testing site, and a source of reassurance during the COVID-19 emergency. By June 2021, nearly three-quarters of pharmacies nationwide were participating in the Federal Retail Pharmacy Program. By early 2024, pharmacies were delivering more than 70 percent of COVID-19 boosters, including most bivalent doses. For a brief shining moment, they were the Camelot of the public health system. And then, with typical American brutality, the country moved on.

The collapse of an overbuilt retail system

Rite Aid entered final liquidation in May 2025, selling off its prescription files to competitors. Walgreens went private under Sycamore Partners in August 2025 after years of losses, prioritizing debt over store density. CVS, which had already closed about 900 stores between 2022 and 2024, shuttered another 271 in 2025. The hero of the COVID-19 crisis became, in scarcely half a decade, the distressed asset. What collapsed was not just a retail format. There was a tragic national misunderstanding: We treated pharmacies as part of the public health system without changing the business model that governs them.

The troubles did not begin with the pandemic. They are the inevitable unwind of an overbuilt system that mistook density for permanence. During decades of unchecked expansion highlighted by CVS’s acquisition of Target’s pharmacies in 2015 and Walgreens’ purchase of nearly 2,000 Rite Aid stores in 2018, chains were built for ubiquity and not restraint.

At peak saturation, multiple chains occupied the same block. This explains why data from hubs like New York can be deceptive: Pharmacy deserts there declined from 1.6 percent to 0.9 percent between 2015 and 2020. Across Los Angeles, Chicago, and Houston, pharmacy deserts have remained concentrated in Black and Latino neighborhoods.

What we are therefore witnessing is not a uniform “market correction.” This is instead a form of medical redlining by algorithm. As retailers “optimize” their footprints, they are closing redundant stores and abandoning lower-reimbursement zip codes. In poorer urban and rural tracts, it eliminates the community’s last remaining pillar of care, and the clinical expertise embedded within it.

The broken economics of pharmacy reimbursement

To understand the paradox, you must stop picturing pharmacies as ordinary retailers. They are perhaps the only businesses where the seller does not set the price and the buyer does not pay it. Reimbursement is dictated by pharmacy benefit managers (PBMs), vertically integrated entities often aligned with insurers and mail-order competitors. This creates a perverse spread in which pharmacies dispense life-saving medications at a net loss while still carrying brick-and-mortar overhead. While the Consolidated Appropriations Act of 2026 recently began the long-overdue work of delinking PBM fees from drug prices, the retail community is still reeling from decades of clawbacks and underwater reimbursements.

For years, pharmacies survived through an internal subsidy: Prescriptions brought customers in, and front-end retail sales supported the business. That model has eroded as consumers shifted to online and big-box retailers. Front-of-store sales have declined, and the margin that once offset prescription losses has largely disappeared. Pharmacists now provide immunizations, counsel patients, manage chronic therapies, and navigate complex insurance systems.

Nearly one-third of U.S. retail pharmacies have closed since 2010. Today, an estimated 50 to 60 million Americans live in pharmacy deserts or limited-access areas, disproportionately affecting Black, Latino, and rural populations.

The clinical cost of pharmacy deserts

When a pharmacy closes, the effects are immediate. Patients lose not just access, but a layer of clinical expertise that operates quietly but critically: the pharmacist who catches dosing errors, flags drug interactions, and navigates insurance barriers in real time. Remaining pharmacies absorb higher volumes with fewer staff, increasing the risk of burnout and medication errors. Patients also lose the continuity of a familiar clinician who knows their medications and history.

These effects extend beyond patients. As physicians, we feel this loss immediately. When a neighborhood pharmacy vanishes, the pharmacist’s invisible work, including resolving insurance rejects, verifying dosages, and catching interactions, falls back onto clinic staff. The pharmacy closure becomes a workforce tax on the primary care physician.

Resolving the pharmacy paradox

The issue is not that pharmacies failed. It is that we asked them to do more without changing how we support them. During the pandemic, pharmacies were treated as essential health care providers, delivering vaccines, testing, and real-time patient guidance. But once the crisis passed, we returned to treating them as retail businesses, subject to the same reimbursement pressures that had already been eroding their foundation. We expanded their role without changing their economics. That is the pharmacy paradox. We have asked them to serve as the backbone of public health while treating them like expendable vending machines.

The pharmacy was never just a store. It was the front door to the health care system, where questions were answered, mistakes caught, and patients known by name. We asked it to become a clinic during the crisis. Then we sent it back to survive as a retailer.

Now that door is closing. And when it does, it will not just be pharmacies that disappear. It will be the easiest, most human point of access to care. The rest of the system will feel that loss, one missed medication, one delayed diagnosis, one overwhelmed clinic at a time. If we continue to treat pharmacies as retail instead of infrastructure, we should not be surprised when the front door to care continues to disappear.

Timothy Lesaca is a psychiatrist in private practice at New Directions Mental Health in Pittsburgh, Pennsylvania, with more than forty years of experience treating children, adolescents, and adults across outpatient, inpatient, and community mental health settings. He has published in peer-reviewed and professional venues including the Patient Experience Journal, Psychiatric Times, the Allegheny County Medical Society Bulletin, and other clinical journals, with work addressing topics such as open-access scheduling, Landau-Kleffner syndrome, physician suicide, and the dynamics of contemporary medical practice. His recent writing examines issues of identity, ethical complexity, and patient–clinician relationships in modern health care. Additional information about his clinical practice and professional work is available on his website, timothylesacamd.com. His professional profile also appears on his ResearchGate profile, where further publications and details may be found.