About four or five times a week, Emerald—a pseudonym to protect her identity—feels a stabbing pain behind her eyes or at the back of her head. Lights get brighter. Sounds are louder, sometimes so loud that they’ll cause her physical pain or make her start vomiting. Emerald suffers from complex migraine syndrome, and at the first sign of an impending attack, she pulls out dihydroergotamine mesylate, a nasal spray that can keep the pain from escalating.
Without the drug, she will start to experience symptoms that make it seem like she’s having a stroke. If things get that bad, she’ll rush to the emergency room. She can spend weeks in the hospital getting intravenous drugs to manage the pain and monitor her brain. In addition to getting migraines, Emerald also has an aneurysm, a small bubble of blood in one of her brain’s blood vessels. If a migraine increases her blood pressure too much, the aneurysm could rupture and be life threatening.
Emerald is an Army veteran and gets her medications through the Department of Veterans Affairs. “You have to receive all your medications through the VA, and it’s a hassle to even request to pick up your refills at the VA,” she says. “You have to call in a prescription and get it mailed.” And recently, her crucial medication hasn’t been showing up on time. Since June, she says, she’s been waiting anywhere from 14 to 28 days for deliveries. “In the past, the longest I ever waited was seven days,” she says. “Now, as soon as I can, we’re calling to try to fill the prescription.”
In June, the United States Postal Service (USPS) made cuts that have slowed mail delivery. Hundreds of sorting machines and post office collection boxes were removed from service, and overtime payments for mail carriers were cut. Postmaster general Louis DeJoy has also suggested that after November the USPS could raise package rates, raise rates for deliveries in Alaska, Hawaii, and Puerto Rico, and require election ballots to be sent using first-class postage. Those cuts could also drastically slow down mail service, and critics such as House speaker Nancy Pelosi and senior-advocacy groups like AARP have criticized their potential to affect the delivery of everything from ballots to financial information to medicine.
The Department of Veterans Affairs sends out 80 percent of its medications through the mail. An August analysis by the Kaiser Family Foundation, based on data from 2018, found that 17 percent of Medicare recipients—over 7 million people—receive at least one medication through the mail. According to data from the investment firm SunTrust Robinson Humphrey, the number of mail-order prescriptions went up 21 percent at the end of March as the pandemic began and people looked for ways to stay out of crowded indoor spaces. At least eight states have also relaxed requirements for signatures for deliveries during the pandemic, making it easier for Medicaid recipients to get their prescriptions by mail.
Like Emerald, other veterans and people who rely on mailed prescriptions are telling their stories to reporters nationwide. Half a dozen staff members at the VA and more than two dozen veterans nationwide told the publication Connecting Vets that they are seeing similar holdups for important medicines. An elderly man in Texas told reporters that USPS delays left him without heart medicine for a week, and people in New Hampshire and Oregon reported similar waits for life-saving drugs like those that treat blood clots and cystic fibrosis.
Advocates are worried that the elderly, disabled, and chronically ill will be left without reliable access to medicine. During the Covid-19 pandemic, when so many older adults and people with underlying health problems are isolating at home to stay safe, the dangers of being forced to visit a pharmacy are particularly worrying. “It’s really critical to understand that people that are most at risk of the slowdown of the mail affecting their ability to get medicines and supplies are exactly the population that is most at risk from Covid-19,” says Jennifer Goldberg, deputy director of Justice in Aging, a nonprofit that advocates for seniors.
Many of them also depend on the mail for medical supplies like canes, or parts for prosthetics or CPAP machines that help treat sleep apnea. For example, a person who has diabetes might also rely on the mail for a supply of tools for managing their condition like insulin, tubes for insulin pumps, and blood glucose test strips.
“A lot of at-home care that happens now requires parts to be sent and replaced periodically,” says Aaron Fischer, litigation rights counsel at the advocacy group Disability Rights California. Fischer points out that insurance companies and suppliers have spent years building up a system that’s based on the mail—so much so that in some places there may be fewer parts available in brick-and-mortar pharmacies. Some medical devices, like insulin pumps, are highly specialized, and local drugstores may not have the right equipment for specific devices or models.
And some medications, like insulin, need to be kept at a certain temperature. Usually, Fischer says, insulin is shipped in insulated containers with a few ice packs. But the medicine can’t be out of the refrigerator for weeks at a time. If the mail slows down too much, Fischer worries the medication will be unusable by the time it finally appears at a person’s door. Fischer, who has type 1 diabetes himself, says concerns about unreliable mail have made him anxious about whether he’ll have enough supplies. “It’s anxiety-producing enough to have a chronic condition that you have to manage every day,” he says, and he worries that other people may start rationing insulin to build up an emergency backup supply.
There are benefits to using mail-order services. Refills can be automatic, which makes it easier for people to take their meds every day and comply with doctors’ orders. For people who don’t drive or have access to other transportation, it also removes the barrier of getting yourself to the pharmacy. That’s especially important in rural or tribal areas, where the nearest pharmacy could be hours away. “It’s not like everybody can just run to their corner drugstore,” says David Certner, legal policy director at the AARP. “Many seniors have mobility challenges. For those folks, mail-in is critical.”
And insurance systems like Kaiser and Medicare encourage using mail-order options by offering customers price deals, like a three-month supply for the price of two. “Taking that away, there’s an efficiency, reliability and affordability component,” says Fischer.
A mail slowdown could be especially devastating for the elderly, many of whom rely on USPS for vital medical and financial information, including updates about Social Security benefits and bank statements. “Social Security sends out 350 million notices through the mail each year, so there’s a ton of information going out to people that’s critical for how they receive their benefits,” says Justice in Aging’s Goldberg. According to a 2019 Pew Research Center survey, 27 percent of people 65 and older don’t use the internet. Goldberg points out that older adults frequently prefer to pay their bills with paper checks, rather than using an online payment system. Being able to use the mail to handle basic issues like personal finance is crucial for older people who want to continue living in their own homes and stay out of long-term care facilities, she says.
The same is true for people living in rural or tribal areas, where access to fixed broadband continues to lag. “A lot of this goes back to being a health equity issue,” says Goldberg, who worries a slowdown will disparately affect rural communities and communities of color, which have higher rates of chronic disease.
For Emerald, in addition to getting her migraine treatment by mail, she also gets muscle relaxants that help her manage chronic back pain. Losing access to those medications can be physically and emotionally difficult. “When you’re confined to a bed and you’re 36 years old, it adds depression and it makes you feel worthless,” she says. And as scary as her migraines are, Emerald is quick to add that her problems pale in comparison to other vets who rely on mail-order medications to treat cancer, depression, schizophrenia, or post-traumatic stress disorder. “There are other veterans that can die,” she says.
The pressure to restore the Postal Service to its pre-pandemic state has been intense. Multiple members of Congress, including the Massachusetts House Delegation, have called for DeJoy’s resignation. The Senate Homeland Security & Governmental Affairs Committee called on him to testify about the Postal Service’s operations during the pandemic and in preparation for the 2020 election. Thousands of people have signed petitions calling on the White House and Congress to protect the Postal Service, and social media campaigns like #saveusps and #savethepostoffice have racked up thousands of likes and reposts. This Saturday, the House passed a bill that would provide $25 billion in funding for the Postal Service, although it has not yet come before the Senate.
“While AARP shares your goal of ensuring the United States Postal Service operates in an effective and efficient manner, we urge you to suspend any adjustments that could negatively affect service during the pandemic,” wrote Nancy LeaMond, executive vice president of AARP, in an open letter to DeJoy posted on August 17. “More than ever before, people are relying on the USPS to deliver their lifesaving prescription medications and other necessities, allowing them to remain safely at home.”
In some ways, the pressure campaign has worked, at least to stall additional cuts. In a statement released the following day, DeJoy announced the USPS wouldn’t implement further cuts to service for 90 days—until the November election is over. But advocates say that’s not enough to ensure adequate and reliable mail service; Pelosi in particular has taken aim at DeJoy, arguing that he has no intention of reducing the cuts he’s already made. In addition to replacing the sorting machines, overtime payments, and post office boxes that were already removed, advocates say Congress needs to fully fund the post office, especially while the pandemic continues. “It’s not enough to say they’ll stop with where we are now,” says Goldberg. “They need to go back and reverse the changes that have already been made.”
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