In downtrodden communities like Rocky Mount, where unemployment has doubled to 14 percent in a year, the recession has heightened the struggle. National surveys consistently find that as many as a third of respondents say they are not complying with prescriptions because of cost, up from about a fourth three years ago.  Many customers at Almand’s Oakwood neighborhood store, particularly those too well off for Medicaid but unable to afford insurance, simply pick and choose among risks. They weigh not taking maintenance medications against more immediate needs like shelter and food.  The pharmacists see it every day. About eight months ago, they stopped automatically preparing refills for regular customers because they found that more than half were not being collected and had to be restocked.  One recent Wednesday, James S. Crawford, newly discharged from the hospital after his third heart attack, fanned six green slips across the counter as if showing a hand of cards. There were a pair for high blood pressure, one each for angina, cholesterol, and acid reflux, and a renal vitamin for his kidney disease. “I need to know the prices,” he said.  Ms. Suber, the pharmacist, explained what each drug was for and listed the co-payments under Mr. Crawford’s Medicare plan, ranging from $8.25 to $18.49 for a one-month supply. The renal vitamin, at $21.89, was not covered.  Mr. Crawford, 61, who makes do on $1,800 a month in Social Security and veterans’ benefits, decided he could afford only the heart, blood pressure and acid reflux pills. “If I can rob a bank,” he said, chuckling, “I’ll be back for the others.”  Before leaving, he handed over yet another prescription, just for safekeeping. It was for Plavix, an anticlotting drug that helps coronary patients avoid new blockages, and it had been written in early February after Mr. Crawford’s second heart attack. At $160, the co-payment was so high he had never considered filling it.  Some customers get by through a patchwork of assistance programs offered by governments, charities and drug makers. The only hospital in Rocky Mount, Nash General, donated about $60,000 in medications last year, and a newly established free clinic is spending up to $600 a month on discounted prescriptions at Almand’s.  But the need is much greater, and the impact is already felt downstream in clinics and emergency rooms where the ailing seek treatment when their diabetes or blood pressure spikes out of control.  Dr. John T. Avent, a physician at a low-income clinic near Almand’s, estimated that at least 80 percent of his patients were not taking prescribed medicines.  “They’ll say, ‘Well, Doc, I just couldn’t afford it; I’ve been out of it for a month now,’ ” Dr. Avent said. “By that time, of course, their blood pressure is highly elevated and their hemoglobin A1C is two to three times what it should be.”  Dr. Daniel C. Minior, who directs the emergency department at Nash General, said he was increasingly hearing from patients that they had lost jobs and could not afford medications. “The worrisome aspect is that it’s even occurring among younger and working-age people,” Dr. Minior said. “That’s not something we saw before.”  Rocky Mount, planted amid tobacco fields in eastern North Carolina, has seen the closings of mills and an exodus of jobs, compounding the devastation caused by flooding from Hurricane Floyd in 1999. The Almand family once owned a dozen pharmacies in the area, but only two survive.  The Oakwood store, in the heart of the African-American community, faces growing competition from mail orders. But business remains steady thanks to discount programs, partnerships with neighborhood clinics, while-you-wait service, $1 delivery and a friendly, familiar staff. Each morning, the pharmacy fills with the aroma of popcorn from the machine on the counter and Gloria Mabry, who runs the cash register, greets customers by calling them Baby or Sugar, whether she knows them or not.  More than 70 percent of the store’s patrons are covered by Medicare or Medicaid, and the pharmacy offers $4 generics to the uninsured. But customers taking a dozen or more medications may still struggle to afford even the modest co-payments under government plans (as low as $3 in the case of Medicaid).  Lisa A. Hylton, 29, from nearby Sharpsburg, said she had skipped twice-monthly refills three times this year on an albuterol inhaler for her asthmatic son, Hunter. Her husband, a pipefitter, had been working only intermittently and could not afford insurance during the idle stretches, Ms. Hylton said. “It makes me feel like I can’t supply for my young-uns.”  Jimmie L. Bryant, 56, had been laid off for a month when he walked into Almand’s with swollen glands and a one-time voucher from the Edgecombe County Department of Social Services. For the first time since he lost his job, the voucher enabled him to fill prescriptions for Synthroid, to control his hypothyroidism, and Xanax, for depression.  Mr. Bryant said he had tried to get refills from his physician, but was told he would have to schedule an office visit for $120, which he could not afford. Even when he was working and had insurance, Mr. Bryant said, he would alternate between the two prescriptions, week to week.  “At the end of the month, I’d have a little bit of what I need in my system,” he explained.  Similarly, Robert E. Brown, 60, who has heart disease and emphysema, said he regularly told the pharmacists at Almand’s to reshelve his prescriptions after being quoted prices of $100 or more. “I just hand them back,” he said. “I take the ones I can afford, and then trust in the Lord.”  A version of this article appears in print on , on Page A1 of the New York edition with the headline: Slump Pushing Cost of Drugs Out of Reach. Order Reprints| Today's Paper|Subscribe
Even with low-cost generics and discounting by big chains, many Americans still find themselves unable to afford their prescription medications.