Access Is Not Enough: Designing Community Pharmacy for Health Equity

Persistent health disparities in the United States are shaped not only by clinical care but also by social determinants of health, the conditions in which people live, work, and age.¹ Millions of Americans reside in areas with a shortage of health professionals, and many communities continue to experience limited access to primary care.² At the same time, 90% of the US population lives within 5 miles of a community pharmacy, and patients visit pharmacies nearly twice as often as primary care providers.^3,4 Few health care settings are as deeply embedded in communities as the local pharmacy. When supported by aligned systems and intentionally designed workflows, this infrastructure can operationalize health equity at scale.

Access alone does not eliminate disparities. Proximity creates opportunity. Design determines whether that opportunity reduces inequity, and design here means more than layout or aesthetics. It means workflow, staffing models, reimbursement pathways, and partnerships that allow care to flex around the realities patients face beyond the pharmacy counter.

Consider a patient initiating buprenorphine for opioid use disorder who lacks stable housing and reliable transportation. Even when prescribing barriers are lowered, sustained treatment depends on timely dispensing, coordinated refill timing, stigma-informed engagement, and proactive follow-up. When those pieces fall apart, we tend to call it a clinical failure. It isn't. It's a design failure. In everyday community practice, these gaps show up not as policy debates but as missed refills, delayed therapy initiation, abandoned prescriptions, and patients who fall through the cracks when care becomes too complicated. In these settings, pharmacy practice can perpetuate gaps in care or help close them. The difference is whether it is adequately supported.

That support takes many forms, but it starts with how care is designed. Intentional workflow design transforms access into continuity. Medication synchronization programs reduce transportation burdens. Structured follow-up supports adherence in the face of economic instability. Coordinated communication with prescribers strengthens fragmented care pathways. Pharmacy networks such as CPESN show what's possible when pharmacies share standards and align with payers, moving from isolated dispensing sites to coordinated care delivery. When workflows are structured to anticipate social barriers rather than react to them, equity becomes embedded in routine practice. It stops being an add-on service and starts being a function of how care is designed.

This design-driven approach matters most where disparities are deepest. Significant treatment gaps in opioid use disorder persist despite the availability of effective medications. The federal removal of the X-waiver requirement in 2023 reduced real regulatory barriers to buprenorphine prescribing, and OTC naloxone approval that same year expanded reach further.^5,6 But availability alone doesn't ensure utilization; that depends on geographic proximity, stigma-informed engagement, patient education, and coordinated follow-up. HIV preexposure prophylaxis reflects the same pattern. Clinical effectiveness and regulatory approval don't automatically translate into sustained utilization, particularly in communities facing layered social barriers.⁷ When barrier reduction is integrated into everyday workflow, community pharmacies extend equity not by adding isolated services but by sustaining access within routine care.

Sustaining this work requires more than professional commitment. Designing workflows to address social barriers demands time, coordination, and consistent support in the midst of already full prescription queues and competing demands. Pharmacists can design the workflows, but the workforce preparation and payment models have to catch up. Emerging value-based models reflect growing recognition that health outcomes are shaped by far more than the prescription itself. Without sustained investment, even well-designed pharmacy programs will remain episodic rather than integrated.

Community pharmacies already reach patients who struggle to access other parts of the health system, and pharmacists have demonstrated the capacity to design workflows that reduce barriers and strengthen continuity. Scaling that impact requires something the pharmacy alone cannot provide: coordinated changes in practice standards, reimbursement models, and professional expectations.

The question is not whether pharmacists can do this work. The question is whether we will align practice, policy, and investment to meet this moment in a way that is scalable, sustainable, and worthy of the communities we serve.

REFERENCES

1. Social determinants of health (SDOH). CDC. January 17, 2024. Accessed March 2, 2026. https://www.cdc.gov/about/priorities/why-is-addressing-sdoh-important.html

2. Health workforce shortage areas. Health Resources and Services Administration. Accessed March 2, 2026. https://data.hrsa.gov/topics/health-workforce/shortage-areas

3. Berenbrok LA, Tang S, Gabriel N, et al. Access to community pharmacies: a nationwide geographic information systems cross-sectional analysis. J Am Pharm Assoc (2003). 2022;62(6):1816-1822.e2. doi:10.1016/j.japh.2022.07.003

4. Berenbrok LA, Gabriel N, Coley KC, Hernandez I. Evaluation of frequency of encounters with primary care physicians vs visits to community pharmacies among Medicare beneficiaries. JAMA Netw Open. 2020;3(7):e209132. doi:10.1001/jamanetworkopen.2020.9132

5. Waiver elimination (MAT Act). Substance Abuse and Mental Health Service Administration. Updated November 6, 2024. Accessed March 2, 2026. https://www.samhsa.gov/substance-use/treatment/resources/mat-act

6. FDA approves first over-the-counter naloxone nasal spray. News release. FDA. March 29, 2023. Accessed March 2, 2026. https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray

7. Killelea A, Johnson J, Dangerfield DT, et al. Financing and delivering pre-exposure prophylaxis (PrEP) to end the HIV epidemic. J Law Med Ethics. 2022;50(S1):8-23. doi:10.1017/jme.2022.30