The states have serious pharmacy access problems, and it’s about to get worse. State lawmakers seeking to address real healthcare concerns are pursuing policies that risk making it even harder for everyday Americans to access care at their local pharmacy.
Nearly 57 million Americans live in a pharmacy desert, generally defined as a high-poverty area with no pharmacies within 1 mile in urban areas or 10 miles in rural areas. In Texas alone, 4.3 million people live in a pharmacy desert. Another 1.8 million Texans rely on a single “keystone” location, where the loss of that pharmacy could also turn their community into a pharmacy desert.
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For American families, access is not just about whether care exists somewhere: It is about whether care is nearby, affordable, and available. Pharmacies are one of the few healthcare doors open at a time when patients can walk through them. That is why lawmakers should think carefully before pursuing reforms that could put this access at further risk.
This year, Congress took an important step in delivering reforms impacting the pharmacy ecosystem, namely pharmacy benefit managers, the behind-the-scenes companies that sit between health plans, drug companies, and pharmacies. PBMs help decide which drugs are covered, how pharmacies are compensated, which pharmacies are in network, and what patients pay at the counter. They can also negotiate significant discounts on behalf of smaller insurers, employers, and consumers.
In the states, PBMs have become popular punching bags, primarily because of spread pricing and steering patients to PBM-affiliated pharmacies. Spread pricing refers to arrangements in which a PBM reimburses a pharmacy at one rate while charging the health plan a different amount for the same prescription. These concerns are about transparency, incentives, and patient choice, not about the pharmacists who serve patients every day.
There are real problems, and real reform is needed. But a real problem does not make every proposed solution the right one.
Arkansas and Tennessee have enacted legislation that bans or restricts pharmacies owned by pharmacy benefit managers, such as CVS Caremark, Express Scripts, and OptumRx. After Arkansas adopted that approach, a federal judge temporarily blocked enforcement of the legislation. Tennessee lawmakers enacted their own version of that law and will likely face a similar legal challenge. Nearby, Texas previously considered a similar proposal to prohibit a PBM from directly or indirectly controlling, or being under common control with, a pharmacist or pharmacy in Texas.
State lawmakers should not copy Tennessee or Arkansas without first asking whether a heavy-handed ownership ban is necessary, whether it will survive legal challenges, and what it will do to communities that already struggle to access healthcare.
None of this means that lawmakers should avoid regulating PBMs or the pharmacy chains affiliated with them. Lawmakers can and should demand transparency, fair dealing, and meaningful penalties and explore other market-driven models that increase access to care.
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But there is a difference between regulating bad conduct and disrupting access for patients who had no role in that conduct. That distinction matters because pharmacies are part of Americans’ healthcare infrastructure. They help patients understand medications, administer vaccinations, provide basic testing, and support people managing chronic conditions.
Lawmakers should address pressing healthcare questions, including the price and accessibility of essential medicines, but they should not blindly adopt policies that could leave vulnerable patients with fewer places to turn for prescriptions, vaccinations, and basic pharmacy care. Smart, free-market reforms could lower costs, protect patients, and make the prescription drug market fairer. These reforms would not do so. In fact, they could create new healthcare deserts.
Naomi Lopez is a healthcare policy expert, founder & principal of Nexus Policy Consulting, and author of The Free Market Remedy for Drug Pricing Ills: A Toolkit for State Lawmakers.
