Americans know how tedious going to the drugstore to pick up a prescription can be. We tend not to acknowledge the similarly trying experience of the person across the counter from us: the pharmacist.

Pharmacists constitute an oft-overlooked group of workers made miserable by our for-profit health care system. It’s easy to mistake the white-coated practitioner on the other side of the pickup window for an arbiter of access and prices, but, in reality, pharmacists have little authority to bend or break the limitations set in place by health insurance companies.

They feel the impact of its injustices as much as their customers. Hannah, a retail pharmacist in New York City who spoke anonymously to avoid retribution from her employer, describes facing the human cost of a broken drug delivery system every day.

“A lot of patients get frustrated with the costs of their prescriptions, understandably. They don’t understand their insurance plan, they aren’t aware they have a deductible before their regular co-payments kick in. We [pharmacists] bear the brunt of that frustration,” she says.

Experts agree: The American pharmaceutical system is in desperate need of reform. Drug prices are higher than ever, and continue to increase at alarming rates. One in five Americans can’t afford their prescriptions; even modest co-pays cause people to skip medication doses. This environment of despair has led to demoralizing work conditions for pharmacists, who, like doctors, mostly go into the field to help people. Unlike doctors, their burnout has flown largely under the radar.

Pharmacists spend much of their time communicating (or trying to communicate) with pharmacy benefit managers or PBMs: essentially middlemen that negotiate drug prices for both patients and pharmacies to determine which benefits are allotted to whom. Each health insurance company, or the PBM it works with, has its own list of medications that are covered under that plan.

The multiplicity and growth in power of PBMs in the United States has led pharmacists to spend more time on billing and reimbursement than on advising worried and sometimes desperate patients. Sometimes this frustration can even escalate to a threat of bodily harm. “I have pharmacist friends, especially women, who had patients waiting out in the parking lot to confront them when they finished their shifts,” says Hannah.

In the face of grave, pervasive inequality, pharmacists do what they can to help. “I’ve had patients who couldn’t afford their medication, even the smallest co-pays, like $3 or $5,” says Hannah. “I just pay for them myself, if the patient will let me. I know I’m not the only one who does that.”

Pharmacists are repositories of horror stories about the real-life impact of the American health care system’s inequities. I spoke to one pharmacist, Aaron (also a pseudonym), who told me about a man in his early 40s, well insured, well off, and otherwise healthy, who developed a blood clot in his leg. The problem: It happened on Thanksgiving Day.

“He went to the emergency room, where they wanted to put him on an expensive, brand-name medication which required a prior authorization from his insurance company,” says Aaron. But because it was Thanksgiving, Aaron couldn’t reach anyone, and when he finally got through to the insurance company, he was told to send the patient to the emergency room instead of being approved to give him enough medication to last the weekend.

“It was maddening,” Aaron continued, audibly upset. “It turned out that the patient was wealthy enough to buy a week’s supply of medicine out of pocket, but if he hadn’t been, he very well may have died. Or he may have returned to the ER, where he would have been admitted to the hospital, which would have resulted in an inappropriate and more expensive treatment.”

Aaron would like to see all health insurance companies abolished. He says they add no value to health care systems. “They just accumulate wealth. They pretend to be part of an integrated system, but they control it. We’re under their thumb.”

Mira Dermendjieva, an emergency medicine pharmacist in Southern California, has also seen the insurance system eat up the lives of her patients—often very ill people who spend much of their precious remaining time left fighting to afford care.

“I had a patient who had received a liver transplant,” she says. “He needs to be on immunosuppressant drugs for the rest of his life, or his body will reject the liver. This gentleman was laid off after the transplant, so now he spends every January writing letter to pharmaceutical companies asking them to include them in their charity programs, so he doesn’t die. That’s just his life now.”

The moral injury of finding herself relatively powerless to alleviate her patients’ suffering can be demoralizing, says Dermendjieva, and the experience of working in the field of pharmacy has deteriorated even since the early 2000s, when she trained.

“The demands on pharmacists’ time are out of control. For instance, 20 years ago, if a patient came in with a prescription for a drug that wasn’t covered or carried a high co-pay, the pharmacist would contact the prescribing doctor or insurance company to get it changed right away. These days, we’ll send a message, but we don’t follow up. The issue just gets filed away. We don’t have time to resolve these sometimes critical situations.”

In other words, pharmacists, like other health care providers, are overworked, under-resourced, and constantly surveilled and exploited by drug and retail industries looking to exploit their labor for maximum profit. Like doctors and nurses, they should not be blamed for working within this system. “These are good, smart clinicians,” Dermendjieva says. “They’re just constantly under the gun, and it’s undermining patient care.”

The devaluation of patient-centered care and increase in pharmacist burnout has driven pharmacists like Dermendjieva to become more politically active.

“I am a huge proponent of Medicare for All. I’ve been volunteering for the Sanders campaign, and I’m involved with a group called Doctors for Bernie—health care providers who have organized to push for single payer. I’ve also been trying to get my colleagues to speak up.”

Shannon Rotolo, a pharmacist at the University of Chicago Medical Center who serves as an officer for the Illinois Single Payer Coalition, and wrote an op-ed for the Chicago Tribune last year advocating for Medicare for All as a partial solution to soaring drug prices and lack of access.

Rotolo attributes dissatisfaction among pharmacists to the changing role of pharmacists toward the administrative and bureaucratic: 60 to 70 percent of her day is spent figuring out how to get people the drugs they need, instead of using her skills.

“You undergo four years of extensive training to get a doctorate. You become an expert in medication therapy, drug interactions, adjusting medications for all kinds of complex conditions, customizing drug therapy to make it the safest and most effective it can be,” she says. “But all of that means nothing if the patient doesn’t have access to it.”

According to a 2019 Gallup poll, pharmacists are the third-most-trusted professionals in America, after nurses and physicians. For this reason, and in light of the coronavirus pandemic, they are likely to take on more and more prominent roles; Rotolo notes that as hospitals in rural areas close, a pharmacist may be a patient’s nearest health care provider—which makes it all the more important that their capacity for true patient care be protected. And, as customer-facing employees who can’t work remotely, they must also guard their physical health, especially from potential patients coming to the drugstore to mitigate viral symptoms.

As the world weathers the rise of this new global health threat, we must make a commitment to securing humane working conditions for pharmacists, and for all health care providers, whom we trust to shepherd us through.