Association for Public Policy Analysis & Management

Policies aimed at improving healthcare delivery and quality, combined with the growth in market-driven healthcare in the U.S., have spurred health system mergers and consolidations, and a shift toward outpatient care. Research on these trends largely focuses on their impact on costs and quality. Less attention has been paid to how changes in the spatial distribution of healthcare delivery may impact access to care. Our analysis draws on spatial data to examine the impact of recent hospital closures or re-structurings and the rise of for-profit specialty care practices, such as urgent care clinics, on access to care for vulnerable populations in four mid-sized cities between 2012 and 2017. We draw on demographic and un-insurance data from the American Community Survey, chronic disease data from the CDC’s 500 cities project, and key informant interviews to examine the impact of healthcare gentrification, or shifts in the type of and spatial distribution of care that favor wealthier residents while potentially excluding more vulnerable residents, in four mid-sized cities: two in states that have not expanded Medicaid under the Affordable Care Act (Dallas, 22.1% uninsured and Atlanta, 12.8% uninsured) and two that have (Philadelphia, 10.6% uninsured and Seattle, 6.0% uninsured). We find that, similar to the way that urban gentrification contributes to demographic changes and increasing income inequality, healthcare gentrification is increasingly allowing the industry to profit from a “health care gap” by closing less profitable facilities in lower-income neighborhoods, and siting new facilities in profitable locations with more insured residents.