Even with the Medicare drug benefit, even with the prevalence of low-cost generics, even with loss-leader discounting by big chains, many Americans still find themselves unable to afford the prescription medications that manage their life-threatening conditions.

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.