How Community-Owned Pharmacies Model Healthcare Solidarity

Start with a number that nobody in policy circles takes seriously enough. The average American visits a pharmacy 35 times a year. The average American visits a primary care doctor fewer than 4 times a year. For people managing chronic conditions — the people consuming most of healthcare's cost — the ratio is even steeper. The pharmacy, not the clinic, is where most healthcare actually happens.

Now add this: pharmacists are the most trusted profession in Gallup's annual poll, consistently in the top three for two decades. More trusted than doctors. More trusted than nurses in some years. That trust was earned in a specific way — by being the person who picks up when you call at 9pm scared about a reaction, by being the person who explains what your doctor didn't have time to, by being the person who remembers your mother's name.

And yet the structure around the pharmacist has been eating itself for twenty years. Let's get the mechanics clear before we talk about alternatives.

Pharmacy benefit managers emerged in the 1960s as paper-claim processors. They helped insurers figure out which prescriptions to pay for. That's it. A clerical function.

Today the three largest PBMs — CVS Caremark, Express Scripts (Cigna), and OptumRx (UnitedHealth) — process around 80% of U.S. prescriptions. Each is owned by or vertically integrated with an insurer and, in two cases, a pharmacy chain. CVS Caremark is owned by the same CVS that runs the drugstore and owns Aetna. OptumRx is owned by UnitedHealth. Express Scripts is owned by Cigna.

The business model works like this:

1. PBM negotiates rebates from drug manufacturers in exchange for preferred formulary placement. 2. PBM sets reimbursement rates to pharmacies — sometimes below the pharmacy's acquisition cost. 3. PBM charges the plan sponsor (employer, Medicare) a different, higher price. 4. The difference — "spread pricing" — is pocketed. 5. Rebates may or may not be passed to the patient. Often they aren't. 6. PBM steers patients to its own mail-order or chain pharmacy via "preferred" network design.

The Federal Trade Commission's 2024 interim report on PBMs — a rare bipartisan consensus document — called this "a system that raises drug prices and squeezes out independent pharmacies." Between 2013 and 2022, roughly one in three independent rural pharmacies closed. The National Community Pharmacists Association tracks closures monthly. The trend line doesn't bend.

This is not a market failure. It's the market working exactly as designed, for the wrong beneficiaries.

In 2004, Brazil's Ministry of Health launched Farmácia Popular do Brasil under President Lula. The premise was simple: essential medicines for chronic conditions should cost nothing or almost nothing at the counter. The government either sold them directly through state-run pharmacies or subsidized their sale through private pharmacies that opted into the program.

By 2011, the "Saúde Não Tem Preço" expansion made hypertension, diabetes, and asthma medications free at the point of sale. Later rounds added contraceptives, Parkinson's medication, osteoporosis drugs, and glaucoma treatments. No co-pay. No prior authorization. Walk in with a prescription, walk out with the drug.

The impact was measurable and large. A 2017 study in Health Affairs found that the free distribution of hypertension and diabetes medications was associated with a 7% reduction in hospitalizations for those conditions among the poorest Brazilians. Medication adherence — the single biggest determinant of chronic disease outcomes — rose sharply. Researchers at Fiocruz and the London School of Hygiene & Tropical Medicine estimated that the program prevented thousands of deaths per year and cost the system less than the hospitalizations it avoided.

When Bolsonaro cut the program's budget between 2019 and 2022, adherence dropped and hospitalizations rose. When Lula restored it in 2023, the trend reversed. It was one of the cleanest natural experiments in health policy in recent memory: fund the counter, people live longer.

Farmácia Popular isn't a cooperative in the strict sense. It's a state-backed solidarity purchasing model. But it carries the same logic: the pharmacy exists to serve the patient, and the state underwrites that reality because market logic left alone won't.

The Alaska Native Tribal Health Consortium (ANTHC) operates one of the most successful Indigenous-controlled health systems in the world. Its pharmacy network serves 180,000+ Alaska Natives and American Indians across a territory larger than Texas, California, and Montana combined. The pharmacists are trained to work with traditional healers. The formulary accounts for the specific disease burden in Alaska Native communities — high rates of H. pylori, specific cancer clusters, seasonal vitamin D needs. Patients aren't treated as edge cases of a mainstream system. They're the center.

In Aotearoa (New Zealand), Māori health providers like Te Whatu Ora run pharmacy services built around whānau (extended family) as the unit of care, not the individual. When you fill a prescription, the pharmacist might ask who else in your family is on the same medication, who's available to help you remember it, whether the dosing schedule conflicts with your work on the marae. That's not a soft touch. It's a clinical practice grounded in the empirical fact that medication adherence rises when the social container around the patient is acknowledged.

In the U.S., the Indian Health Service (IHS) pharmacy system and 638-contracted tribal pharmacies serve a similar function. Pharmacists work at the top of their license — prescribing, monitoring, managing chronic disease directly — in ways that state laws would prohibit in the private sector. Outcomes in tribally-managed pharmacies often beat the national average for the same conditions, despite serving populations with deeper poverty and less infrastructure.

The through-line: sovereignty changes what the pharmacy is for. When the community owns the institution, the institution serves the community. When an outside corporation owns it, extraction follows.

American drug cooperatives have a long and uneven history. Group Health Cooperative in Seattle, founded in 1947, included a pharmacy benefit for its member-owners and was swallowed by Kaiser Permanente in 2017. HealthPartners in Minnesota, also member-governed, still operates. Food co-ops in the Pacific Northwest and Midwest sometimes include pharmacy services. Senior-focused pharmacy co-ops exist in pockets.

The newer wave is different. Cost Plus Drugs, launched by Mark Cuban in 2022, isn't a co-op — it's a public-benefit corporation — but its pricing model is cooperative in spirit. It publishes the acquisition cost of every drug, adds a 15% markup and a small pharmacy fee, and sells at that price. Imatinib, a leukemia drug that some PBM networks price at $2,500/month, sells on Cost Plus for under $35. That isn't a discount. That's what the drug costs.

The reaction inside the industry was telling. PBMs didn't compete on price. They lobbied states. They tightened network exclusions. They raised the spread on other drugs to compensate. In other words, they treated transparency itself as the threat. It was.

Meanwhile, on the policy side, states including Colorado, Maryland, Washington, Oregon, and Minnesota have created Prescription Drug Affordability Boards — regulatory bodies with the power to set upper payment limits on specific drugs. It's not quite a cooperative, but it's a public-purpose intervention in the price-setting process that mirrors what co-ops do privately.

Member-owned buying groups — Independent Pharmacy Cooperative (IPC), American Pharmacy Cooperative (APCI), Federation of Pharmacy Networks — let small independents pool their purchasing power. They won't solve the PBM problem alone, but they're the reason there are still independent pharmacies left to solve it with.

Strip it to the practical differences, not the ideology:

1. Price discipline comes from ownership, not negotiation. A member-owned pharmacy doesn't need to negotiate a good price for its members — the members are the pharmacy. Surplus stays in the community. This is the single biggest structural difference.

2. The formulary serves the population, not the manufacturer. Farmácia Popular carries drugs that Brazilians actually need. ANTHC carries drugs that Alaska Natives actually need. Neither formulary is shaped by rebate flows. This sounds obvious and is almost unheard of in the U.S. private sector.

3. The pharmacist practices at the top of their license. In community and tribal pharmacies, pharmacists run chronic disease management, adjust doses, counsel patients for 15-30 minutes at a time. In chain pharmacies, they dispense 400+ prescriptions per shift and can't. Same training, totally different job.

4. Cultural and linguistic fit is the default, not an add-on. When the pharmacy is owned by the community it serves, the person behind the counter looks like, speaks like, and understands the patient. Adherence rises because trust rises. This is measurable, not sentimental.

5. Hours and location follow need, not shareholder math. A chain closes a branch when the spreadsheet says so. A co-op closes a branch when the neighborhood decides it's time. Those are different decisions.

The solidarity pharmacy isn't a feel-good bypass of the hard problems. The hard problems come for it too:

- PBM reimbursement contracts often make participation in insurance networks financially impossible for small pharmacies. Refuse to sign and you lose most of your patient base. Sign and you lose money on many scripts. - Manufacturer rebate structures reward volume and exclusive placement, both of which favor chains. - Regulatory asymmetry — state pharmacy boards often apply the same compliance burden to a small co-op and a CVS, which favors the entity with a compliance department. - Capital access — opening a pharmacy requires inventory financing that banks won't extend to a cooperative without collateral or established revenue. - Workforce — pharmacists trained in chain-dominant curricula often don't know how to practice the community model. Residency pipelines matter.

None of these are fatal. All of them are the reason the movement grows slowly.

When you walk into a pharmacy — any pharmacy — ask three questions. The answers tell you what kind of institution you're in.

1. Who owns this? Chain, PBM-affiliated, independent, cooperative, tribal, state? 2. Who does the surplus flow to? Shareholders, members, patients, community reinvestment? 3. Can the pharmacist spend 15 minutes with me? If no, the institution has been designed to extract, not to care.

Use this test before you switch your prescriptions. Use it when you're choosing where your employer plan routes you, if you have the choice. Use it when local officials ask for your input on health policy.

- Federal Trade Commission. Pharmacy Benefit Managers: The Powerful Middlemen Inflating Drug Costs and Squeezing Main Street Pharmacies. Interim Staff Report, July 2024. - Emmerick, I. et al. "Access to Medicines in the Brazilian Unified Health System: A Critical Analysis of Farmácia Popular." Ciência & Saúde Coletiva, 2015. - Silva, R. et al. "The Impact of Free Access to Medicines on Hospitalization Rates in Brazil." Health Affairs, 2017. - Alaska Native Tribal Health Consortium, Annual Reports 2018–2024. - National Community Pharmacists Association. Digest Annual Reports. - Fein, Adam. Drug Channels Institute: Economic Report on Pharmacies and PBMs. Annual series. - Cost Plus Drugs. Public pricing database. costplusdrugs.com - Hwang, T. et al. "Prescription Drug Affordability Boards and the Limits of State-Level Price Regulation." NEJM, 2023. - Sanchez, Kwame et al. "Cultural Competence in Pharmacy Practice: A Systematic Review." Journal of the American Pharmacists Association, 2021.

1. Map your pharmacy landscape. Within a 10-mile radius of your home, list every pharmacy. Mark which are chains, independents, cooperatives, or clinic-affiliated. You'll see the geography of extraction.

2. Find out who your PBM is. Look at your insurance card or benefits portal. Note the name. Look up who owns it. Note the vertical integration with a pharmacy chain or insurer. This is the structure operating on your body.

3. Try the three-questions test. Next prescription, walk in and actually ask. Note the reaction. Pharmacists generally know the answer and will tell you if asked plainly.

4. If you employ people, audit your plan. Ask your broker for the PBM contract. Ask whether rebates are passed through. Ask about spread pricing. The fact that you have to ask is itself the problem.

5. If you're a patient of an independent or community pharmacy, tell them. Tell your doctor you want prescriptions routed there. Tell your neighbors. The model survives on referral, not on advertising budget.

6. Write one letter. To your state attorney general or insurance commissioner about PBM transparency. To your member of Congress about the Prescription Drug Affordability Board model. Fifteen minutes. It matters more than social posting.

A pharmacy is a test of how a society answers the question: when someone is sick, who belongs to them?

In the extractive model, nobody. They belong to a claim file.

In the solidarity model, all of us. That's what "we are human" means when it hits the ground and moves a body through a door with a bottle of pills in hand.

The counter is small. The question it answers is not.