Basin Pharmacy fills more than prescriptions in rural northern Wyoming. It’s also the key health care access point for the town of about 1,300 people and the surrounding area.

It sells catheters, colostomy supplies and diabetic testing strips. The storage room contains things that people rely on to survive, such as a dozen boxes of food for patients who must eat through tubes. The pharmacy fills prescriptions in bulk for the county jail, state retirement center and youth group homes. Some patients come from Jackson, five hours away by car, for the specialized services.

Pharmacist Craig Jones makes house calls when no one else can, answers his phone at all hours of the night and stops to chat about bowel movements at church. Yet Jones keeps a pile of his own paychecks on a desk in the back of his pharmacy. Four months’ worth, uncashed.

“Every year, it’s a little worse,” Jones said of the financial pressures on his business.

Rural pharmacies, independent or chain, can be a touchstone for their communities. The staff knows everyone’s names and drugs, answers questions about residents’ mail-order prescriptions or can spot the signs of serious illness.

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But rural pharmacies’ business models face unrelenting pressures to the point that sometimes they have to close. Several largely rural states have some of the lowest number of pharmacies per ZIP code, according to an AP analysis of data from 49 states and the National Council for Prescription Drug Programs.

The closest pharmacy to Basin Pharmacy is eight miles away in Greybull, and Jones and two other pharmacists opened it after the department store chain that ran its predecessor went bankrupt.

EFFECTS OF A CLOSURE

When a pharmacy does close in a rural area, communities feel the absence.

In Herscher, Illinois, news came out of nowhere that the CVS would shut down in early March.

Mayor Shannon Sweeney met with CVS representatives and asked them to delay the closure for his village of 1,500 that’s 80 miles south of Chicago, but he said the company told him the front of the store was not making enough money.

Pharmacy access is an important consideration, CVS spokesman Matt Blanchette told The Associated Press, but the company also weighs local market dynamics, population shifts and the number of stores in the area selling similar products. He confirmed the meeting with Sweeney, but did not directly answer a question about what financial issues led to the store closure.

Tammy McLearen came to the CVS twice a month to pick up medications for her blood pressure and cholesterol on her way to and from work near Kankakee.

She moved her prescriptions to the CVS near work because she doesn’t want to get them through the mail; her village isn’t a top priority for snow removal in the winter — and her late husband’s heart medications would often get lost in the mail.

“We’re losing convenience, a staple,” she said of the pharmacy, which was part of a small statewide chain before CVS bought it in 2017. “I hope another pharmacy goes in here.”

Sweeney said that’s his goal — preferably an independent one. But in the months since the closure, two promising leads have dried up, leaving the them “dead in the water,” he said.

FINANCIAL PRESSURES

Four of Wyoming’s independent pharmacies closed last year, said Melinda Carroll, legislative director of the state’s pharmacy association. Two more, one independent and one chain, closed so far this year.

Jones plans to hold out in Basin. He owns two other businesses there — a café next to the pharmacy and a grocery store, for which he cashed in some of his retirement accounts to keep it from closing.

But some 25% of the prescriptions he fills today are reimbursed for less than what he bought the medications for. Jones said he lost $30,000 between the beginning of the year and mid-May.

Hence, the uncashed checks.

“I’m working for free a lot,” he said. “And I don’t mind. I love to serve the community. But I kind of resent having to do that because of large corporations, huge pharmacy benefit managers, that are making millions of dollars a year.”

Pharmacy benefit managers, or PBMs, help employers and insurers decide which drugs are covered for millions of Americans.

And the the lack of transparency around fees and low reimbursements from is one of the biggest financial pressures for rural pharmacies, said Delesha Carpenter of the University of North Carolina at Chapel Hill, who leads a research alliance of more than 140 rural pharmacies and seven universities.

But Greg Lopes, a spokesman for the Pharmaceutical Care Management Association that represents PBMs, disputed PBMs’ role in closures and noted that some companies work with rural pharmacies to get higher reimbursements for drugs.

Jones came back to the Basin area after pharmacy school. His daughter Camilla would come into the pharmacy with him on Sundays and he’d quiz her on different medications.

She’s now the president-elect of the state pharmacy association and helps run the Basin pharmacy.

“We’ve definitely tried to do everything we can to run lean to find other options to try and make money to keep our doors open so we can continue to serve patients,” Camilla Hancock said. “But when you’re working so hard and you’re trying your darndest to accomplish these things, and you just kind of get kicked in the gut over and over, it’s really disheartening.”

If it weren’t for the “devastating” impact on his daughter’s future, Jones admitted, “I’d pack it in.”

“I wish I could say I had this healthy, wonderful business I could hand off to my daughter,” he said. “But I worry whether it’s even going to be worthwhile for her to take it over if we can’t make a profit on it or even pay our own wages.”

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Associated Press data journalist Kasturi Pananjady in Philadelphia contributed to this report. Shastri reported from Herscher, Illinois.

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The Associated Press Health and Science Department receives support from the Robert Wood Johnson Foundation. The AP is solely responsible for all content.