Cole and Franzosa  International Journal for Equity in Health (2022) 21:66 https://doi.org/10.1186/s12939-022-01669-6 COMMENTARY Open Access Advancing urban health equity in the United States in an age of health care gentrification: a framework and research agenda Helen V. S. Cole1,2*   and Emily Franzosa3,4 Abstract Background: Access to health care has traditionally been conceptualized as a function of patient socio- demographic characteristics (i.e., age, race/ethnicity, education, health insurance status, etc.) and/or the system itself (i.e., payment structures, facility locations, etc.). However, these frameworks typically do not take into account the broader, dynamic context in which individuals live and in which health care systems function. Purpose: The growth in market-driven health care in the U.S. alongside policies aimed at improving health care delivery and quality have spurred health system mergers and consolidations, a shift toward outpatient care, an increase in for-profit care, and the closure of less profitable facilities. These shifts in the type, location and delivery of health care services may provide increased access for some urban residents while excluding others, a phenomenon we term “health care gentrification.“ In this commentary, we frame access to health care in the United States in the context of neighborhood gentrification and a concurrent process of changes to the health care system itself. Conclusions: We describe the concept of health care gentrification, and the complex ways in which both neighborhood gentrification and health care gentrification may lead to inequitable access to health care. We then present a framework for understanding health care gentrification as a function of dynamic and multi-level systems, and propose ways to build on existing models of health care access and social determinants of health to more effectively measure and address this phenomenon. Finally, we describe potential strategies applied researchers might investigate that could prevent or remediate the effects of health care gentrification in the United States. Keywords: Health care access, Gentrification, Health equity, Urban health Background Black, publicly insured and uninsured patient popula- The 2019 closure of Hahnemann University Hospital in tion, was rumored to be replaced with a more profitable Philadelphia’s rapidly gentrifying city center following its real-estate venture. In the ensuing months, the impact of sale to a private equity investor captured national atten- Hahnemann’s closing was felt deeply as neighboring hos- tion. The safety-net hospital, which served a primarily pitals absorbed increased emergency traffic [1], and Black Philadelphians who had relied on the hospital were hard hit by the COVID-19 pandemic [2]. While Hahnemann’s *Correspondence: helen.cole@uab.cat 2 Healthy Cities research group, Department of Epidemiology and Public was an especially high-profile closure, it is only one of Health, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), many across the United States (U.S.) that represent a Barcelona, Spain broader, complex shift in the type, location and delivery Full list of author information is available at the end of the article © The Author(s) 2022, corrected publication 2022. 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The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Cole and Franzosa International Journal for Equity in Health (2022) 21:66 Page 2 of 10 of urban health care services that we term health care that is wealthier, whiter, has a higher level of formal gentrification. education, and is able to afford new or renovated, more Just as urban gentrification brings amenities and ser- expensive homes while also fomenting new cultural and vices for new, affluent residents to formerly underin- consumption practices [8]. Neighborhood gentrification vested neighborhoods, health care gentrification in is closely linked to patterns of uneven development and U.S. cities, occurring concurrently and in addition to deprivation which have long been understood as social neighborhood gentrification, provides increased access determinants of health and to lead to health inequities to health care for some residents while excluding oth- manifested as differences in health outcomes between ers – primarily minority, low-income, and uninsured residents of different types of neighborhoods. Studying or publicly insured patients. For instance, while safety- the health effects of gentrification goes beyond more net hospitals like Hahnemann in gentrifying areas are traditional research on neighborhood health effects by increasingly closing due to financial pressures, these highlighting how neighborhoods change over time, and same neighborhoods are seeing an influx of urgent care how these changes may impact social and health inequity centers and specialty outpatient practices targeted to among communities residing in the same neighborhood privately insured patients [3]. Our emerging research in environments [9]. four U.S. cities suggests that health care gentrification, Emerging research suggests that while gentrification exacerbated by socio-spatial inequities made worse by may be beneficial for the health of dominant racial, eth- neighborhood gentrification, may be driving inequities in nic or class groups (so called “gentrifiers”), it can harm health care access and, in turn, population health. that of ethnic or racial minorities (particularly Black In this essay, we argue that research on urban health residents) or lower socioeconomic classes, who are often care access must be considered within a broader urban long-term residents, exacerbating health inequalities [10, planning framework, taking into account broader 11]. There are a number of hypothesized mechanisms changes occurring in cities that drive health care gentrifi- by which neighborhood gentrification may affect health, cation. We start from the understanding that health care including changes in neighborhood social dynamics, systems do not exist in isolation but are part of complex social networks and support; exclusion of long-term or urban systems. We focus on the city-scale because cit- lower income residents from health promoting neighbor- ies themselves experience a high degree of socio-spatial hood resources (such as parks, healthy food stores, and inequities in health, are unique in that they are often others); increased instances of violence and insecurity; tasked with ensuring the health of residents, yet lack and the stress of threat of or actual displacement and control of health care systems which, in the U.S., consist housing instability [12, 13]. The complexity of neighbor- largely of private entities governed by multiple levels of hood social environments also has significant implica- state and federal laws, regulations and payment mecha- tions for the provision of high-quality health care. Health nisms [4, 5]. care providers struggle to diagnose and treat patients Our framework considers access to high-quality health facing complex social conditions such as homelessness, care services to be a critical resource for healthy and inadequate housing, exposure to violence, and others equitable neighborhoods, and one that may be threatened [14], and neighborhood gentrification may exacerbate by health care gentrification [6, 7]. To better understand these issues, particularly for marginalized residents. For the complex interplay of factors affecting access to health instance, one study found that residents displaced from care, we first describe the relationship between neigh- gentrifying neighborhoods were more likely to visit borhood and health care gentrification and its potential emergency rooms for mental health-related reasons and impact on accessing and providing high quality health to be hospitalized for mental health issues [6]. care. We then present a framework for understanding health care gentrification as a function of dynamic and Health care gentrification and urban health equity multi-level systems and propose ways to build on existing While research on neighborhood gentrification models of health care access and social determinants of and health often focuses on the health impacts of health to more effectively measure and address this phe- gentrification on residents, health care gentrification nomenon. Finally, we describe potential strategies to pre- refers specifically to the impact of changing distribution vent or remediate the effects of health care gentrification. of health care resources within a community on residents’ abilities to access health care they need, taking Neighborhood gentrification and urban health equity into account differences in financial means and health Gentrification is a process of neighborhood change needs by social group. Much in the same way that income through which the demographic, real estate, and business inequality and consistent underinvestment in certain characteristics of a place transition toward a population neighborhoods create conditions in which neighborhood Cole and Franzosa International Journal for Equity in Health (2022) 21:66 Page 3 of 10 gentrification flourishes, inequities in income and wealth, [25]. To maximize revenue and minimize loss, health insurance status, and privatization of services put health systems can also restrict access by changing the supply care resources at risk for gentrification. Our interest is of care by limiting capacity, refusing patients, charging in understanding what these changes mean for equity in higher prices, or not providing culturally or linguistically accessing health care. appropriate providers [26–28]. For instance, many pro- Within the U.S. health care system, the location of ser- prietary urgent care clinics do not accept Medicaid, the vices is driven by multi-level factors, including a mix of public health insurance for lower-income individuals [29, federal and state policies and regulations (for instance, 30]. Policy and regulations can also limit provider supply; siting federally-qualified health centers, or “FQHCs”, that while the Affordable Care Act was designed to increase are charged with delivering community-based care in access to health insurance, differences in the adoption areas of highest need) and payments from insurers and and implementation of health care exchanges and Medic- individuals [15]. Within this system, the growing trend aid expansion have exacerbated inequity between states, toward more efficient, profitable, and value-based care and often by race and social class [31, 32]. that rewards “quality” over quantity of services has incen- tivized providers in new ways [16, 17]. As private health A health care gentrification framework care systems increasingly consolidate and acquire hospi- Placing health care access within the context of tals, provider practices, and services like labs and radi- neighborhood environments, we present the health ology centers [18], they also capture more revenue and care gentrification framework (Fig. 1) to guide the geospatial advantage. From a health care gentrification formation of new research questions and methods. standpoint, when large private “megasystems” consoli- We conceptualize access to health care as a function of date, it makes business sense to shutter underperform- changing social and physical neighborhood environments ing hospitals, close less profitable service lines such as over time, and as a function of the dynamic health maternity or emergency care, and invest in higher-profit care system, both of which are influenced by policies, specialty practices such as cardiology or neurology. The regulations, and private actors at the national, state and shift toward outpatient care has also proven a lucrative local level. Thus, we frame the understanding of health opportunity for private equity investors, who have put care access within the context of inequities created by significant resources into health care ventures for profit neighborhood gentrification, further exacerbated by [19, 20]. inequities in access to care resulting from recent changes In addition to offering more profitable types of care, to health care systems. comparatively low reimbursement from public govern- As neighborhoods gentrify, residents may lose a usual ment-funded insurance such as Medicare and Medicaid source of care as they or their providers are displaced or drives health care providers to seek out more profitable have to travel further for care. But our research suggests patients by prioritizing the needs and preferences of the more complex, and important, connections between commercially insured. “Payer mix”, or the proportion of neighborhood and healthcare gentrification as well. For patients insured privately through commercial health instance, health care gentrification becomes entwined plans, is a strong driver of the distribution of health care with neighborhood gentrification via real estate specula- services geographically [21]. Efforts to improve payer mix tion. The “rent gap” [33] of a failing hospital is quite large. by siting outpatient and specialty services in gentrifying That is, a failing hospital could gain substantial profit if areas may leave uninsured or publicly insured residents transferred to another use such as market-rate housing, without a source of care, even though these patients are and even more so if it is located in a gentrifying neigh- more likely to have urgent or severe health needs, and borhood where property prices are rising, as occurred depend on neighborhood providers because of limited with Philadelphia’s St. Joseph’s Hospital and Queens, mobility or access to transportation [22]. In addition, New York-based St. John’s hospital, to name a few [34, demands (and ability to pay) for different types of ser- 35]. vices and the desire to avoid wait-times may also drive The interaction between these neighborhood and providers to create new settings such as “walk in” clin- health care factors may either promote or reduce access ics, free-standing emergency rooms, or concierge care to health care services. Access to high quality health care providing on-demand direct access to physicians, at a is essential for maintaining health, providing lifesaving price [23, 24]. This means private providers may siphon treatment for acute health conditions, injuries, illnesses, off more profitable residents, leaving overburdened and and both prevention of and ongoing treatment of chronic underfunded public and charitable systems to fill the gap. disease and disability. Access to care also plays a sali- The location of health care services is only one facet ent role in maintaining health equity within and among of health care access, and in turn, distributional equity populations. We maintain that marginalization of certain Cole and Franzosa International Journal for Equity in Health (2022) 21:66 Page 4 of 10 Fig. 1 The relationship between neighborhood gentrification, health care gentrification, and equity in health care access social groups due to widespread poverty and systematic care systems (i.e., payment structures, locations, and racism, entwined with neighborhood racial and class seg- management). Focusing on the U.S. health care system, regation, produce conditions in which both the burden of Aday and Anderson, for example, measured both disease and access to care are not equitably distributed potential and realized access to care through utilization [36, 37]. Thus, to ensure equity in access to care, health and outcome measures [38]; while Penchansky and care systems must distribute (and be incentivized to dis- Thomas framed access as the “fit” between patients’ tribute) services based on these needs rather than profit need and the system’s ability to meet them through five and demand from privileged communities. dimensions: availability, accessibility, accommodation, acceptability, and affordability [39]. More recently, Considerations for measuring health care gentrification Fortney et al. extended this framework, proposing that Measuring the processes and impacts of health care “fit” should include geographical, temporal, financial, gentrification can start by building on decades of health cultural and digital dimensions of access, as well as services and public health research to identify the many patients’ own perceptions of their access to care and need factors determining access to health care. These include for care [40]. Levesque and colleagues similarly proposed not only providers’ geographical locations and capacity incorporating patient dimensions, including the ability of in relation to the population and systems characteristics individuals and populations to perceive, seek, reach, pay such as payment structures and gatekeeping policies, for and engage with the health care system [25]. but also characteristics of patients themselves (i.e., However, operationalizing these models has been socioeconomic status or language) and of health challenging and reveals limitations in measuring this Table 1 Domains of health care gentrification, potential measures and data sources Cole and Franzosa International Journal for Equity in Health Domain Potential measures Potential Data Sources Health care utilization Patient visits to health care facilities, receipt of screening services for chronic Surveillance or survey data from city, state or national agencies; survey data; qualita- disease, vaccination rates, types of services and facilities used tive data from neighborhood residents Health care access Provider supply/population, location, types of insurance accepted, wait lists and Census and survey data, city and state health department surveillance data, Qualita- wait times, cultural competency tive data from neighborhood residents (2022) 21:66 Neighborhood gentrification Gentrification index; perceived gentrification measures; local knowledge and Census and survey data; qualitative data from neighborhood residents experiences Health care system Health systems acquisitions, mergers and closures; staff layoffs/restructuring; Media coverage; closure plans; local government hearings; qualitative research with opening of new facilities, practices and types of services health care system administrators and workers Policy Regulation of medical licensing, facilities and training; scope of practice laws Federal, state and local laws and regulations; federal register; policy documents; government hearings; media coverage Page 5 of 10 Cole and Franzosa International Journal for Equity in Health (2022) 21:66 Page 6 of 10 complex and multi-dimensional construct, particularly system-level measures at multiple levels (local, state and from a health equity standpoint. In practice, studies of national) to identify the impact of broader political and access often focus on proxies for utilization using cross- policy structures on how health care resources are allo- sectional analyses of national survey data; however, cated. Data and methods to answer these questions may as Ricketts and Goldsmith have noted, these types of be drawn from related fields such as the environmental measures tend to relate to discrete events and outcome justice movement [47], which complements and expands measures at the individual level, and relatively fixed on the more traditional health services and social deter- variables at the population level, such as overall insurance minants of health frameworks by joining concepts of coverage, making it difficult to identify broader trends access as a function of the distribution of services with and drivers, and to measure the impact of spatial, social a deeper look at the underlying political, governance and and organizational changes over time [41]. In addition, economic factors contributing to inequitable access to many of these measures fail to account for the social and care and by conceptualizing health care itself as a part of political structures driving access measures, highlighting the broader urban environment. the need for new and more expansive models that go beyond health services to examine broader systems. Cyr, A health care gentrification research agenda for instance, suggests placing domains of access within To ensure equitable access to quality health care in U.S. a social ecological framework, and identifies emergent cities, there are several areas of investigation which domains including the role of government and insurance deserve focus—primarily research into the causes, policy (for instance, government-funded medical effects, and measurement of health care gentrification training programs that can redistribute medical students and broader urban processes which may affect who has to underserved areas) and the influence of health access to high quality health care that meets their needs. organizations and operations, an important factor as Thus, here we consider how research on access to health health systems increasingly re-organize and consolidate care can be made more equity-centered by consider- [42]. Finally, a reliance on aggregate national survey data ing not only the characteristics of patients and provid- and geospatial data may overlook the lived experiences of ers/health care systems that predict access, but also the individuals and communities. underlying drivers of provider/systems characteristics Similarly, neighborhood gentrification research has that lead to more or less equitable access to care. Drawing both benefits and drawbacks to adding to our under- on an ecological model and Purnell et al’s work on fac- standing of health care access. Research on gentrification tors influencing disparities in access to care, we propose and health has primarily employed quantitative meas- research questions and interventions that these questions ures derived from census and other data as proxies for might examine at the policy/regulatory, organizational, gentrification, which are then considered as an exposure community and individual level (summarized in Table 2). in epidemiological models measuring risk of specific or Many of these questions and interventions cross multiple general health outcomes [9, 43]. Some have also consid- levels, highlighting the importance of multi-level, mixed ered the role of gentrification as a moderator in meas- methods research and intervention targets [48]. uring the effects of other exposures such as the benefits First, a key aspect of measuring this phenomenon is of exposure to health promoting resources in cities [9], ensuring that measurements of access to care (which we e.g., showing the benefits of access to green space, while understand to be the primary outcome of interest) are improving health at a population level, may not reach conceived broadly, considering indicators of equity in lower-income or less educated residents [44]. A few stud- access like provider supply, location, types of insurance ies have also used qualitative methods such as interviews, accepted, waitlists and wait times, and whether providers focus groups or photovoice to tease out the mechanisms reflect the racial, cultural and linguistic makeup of the by which gentrification may affect health, and particu- communities they serve. Here we borrow measures of larly the health of long-term residents, and understand equity in access from those used in research of “universal and translate community members’ experience of access systems”, conceptualizing equity in access as a supply-side into person-centered measures [7, 14, 45, 46]. phenomenon that determines whether the services that A summary of potential measurements is included users need are provided to all who need them [49]. Such in Table 1. While existing cross-sectional measures and measures, when combined with city and neighborhood geospatial data are important and helpful in identifying health data, could help cities identify resource gaps and broader trends, we believe that measuring the nuances improve equity in access to care. Importantly, we consider of health care access must also include longitudinal data a neighborhood’s health care resources to include a range to understand dynamic change over time (such as those of private hospitals, physician and specialty practices, measures tracking gentrification, itself a change) and urgent care centers, and community and faith-based Cole and Franzosa International Journal for Equity in Health (2022) 21:66 Page 7 of 10 Table 2  A sample of proposed healthcare gentrification research questions and interventions Level of Inquiry Potential Research Questions Promising Interventions to Study Policy/Regulatory • How are national, state and local policies influenc- • Centers for Medicare and Medicaid Services innova- ing providers’ organizational behaviors? tion grants and waivers (federal) • What are the effects of these multiple levels of • Medicaid design and payment (federal/state) policy/regulation on cities’ health resources? • Licensing, regulation, scope of practice laws (state) • What tools does local government have to influence • Enforcement of community benefits requirements health resources? (state) • What is the role of health resources in cities’ urban • “Healthy Cities” commitments (local) planning agendas? Organizational/health system/provider • What is the role of private capital on provider • Rent control and rent regulation organizational behavior? • Community land trusts • How do health systems prioritize location and types • Developer incentives of services offered? • Landlord tax abatements • How do health systems align organizational goals • Limits on or transparency/disclosure of private equity with health equity and access concerns? investment • Local laws directly targeting health system closures and restructuring • Organizational equity and access initiatives Community/Intrapersonal • How are public and private health resources utilized • Local hiring and procurement initiatives by health within communities, and who utilizes them? systems and cities • What are the economic effects of health system • Participatory planning processes for development, changes on communities? zoning, city planning • What are the employment effects of health systems • Tenant and resident organizing movements changes on communities? Individual • How do changes in the location and type of care • Patient education and clinical care initiatives affect residents’ perceptions of their local health • Patient engagement groups and advisory councils resources? • How do changes in location and types of care affect whether residents use or do not use local health resources? What groups are disproportionately affected by these changes? services, as well as public services like city-operated which public policies and regulations at the national, state clinics, and county hospitals. It is the care provided and local level drive public and private investments? How by these institutions together that determine whether are these drivers influencing providers’ organizational residents of a neighborhood have sufficient access to behavior, and in turn, the supply of neighborhood quality health care, but existing research often considers health care services? For instance, local governments specific types of healthcare services or providers, often lack power and oversight to respond to health rather than the full landscape. Definitions of private vs. care gentrification and its implications despite holding public services are also not clear-cut. Privately-owned much of the responsibility of ensuring the health of facilities receive public funding in the form of Medicaid their cities’ residents. While health care delivery systems or Medicare dollars, federally-funded residency slots, in the United States straddle the public and private and tax breaks for providing community benefits, while realms, private capital is increasingly prominent. At the publicly subsidized FQHCs may be operated by private state level, health care gentrification may be mediated non-profit partners [50]. This makes the impact of by policies and programs like Medicaid expansion or public and private investments and policies, key factors waiver programs that make providing care to lower- in studies of neighborhood gentrification, particularly income individuals a better value proposition. But at a challenging though important to disentangle. In terms local level, cities have limited tools to influence private of measuring health care gentrification itself, developing health care businesses; they cannot force hospitals to stay a measure similar to those indexes which have been open, or private clinics to locate in the areas of highest developed for measuring neighborhood gentrification need. The tools that they do have – control over zoning could help to establish results that are comparative across or tax abatements - do not make up for the low revenue contexts or places. of operating a safety net hospital or clinic, particularly We also need to better understand the impact of the if they continue to lose commercially insured patients. multi-level policy and regulatory environments on Questions around how state and federal regulations play provider behavior. What are the specific pathways by out at the local level are particularly important when Cole and Franzosa International Journal for Equity in Health (2022) 21:66 Page 8 of 10 considering the growing role of private equity, whose local hands. For instance, rent control and regulation influence is effectively a black box due to the limited are city-level measures that have been explored as a reporting requirements and regulations on many private way of preventing displacement associated with gentri- specialty services. The answers to these questions can fication. Other options include community land trusts help determine key leverage points for action. which return control of land and land-use to residents, Critically, we note that research on health care gentri- zoning regulations, developer incentives and tax abate- fication must take into account the lived experience of ments to incentivize landlords to maintain affordable neighborhood residents. Currently, many health systems rents [53]. Similar measures might prevent health care and regions conduct community needs assessments. But gentrification by supporting community health cent- these assessments often rely solely on clinical and sur- ers and incentivizing providers to remain in or move to veillance data from local health care agencies and pro- neighborhoods where they are needed. Local policies viders, without including the perspective of patients and may also target health care gentrification directly; Phil- community residents. Resident perspectives, which can adelphia, for instance, passed a measure to gain more be assessed using qualitative methods such as interviews, local control over hospital closures by increasing the focus groups, participatory methods such as process notice hospitals must give before closing, and requiring mapping, or uniquely designed surveys, not only identify them to submit a detailed closure plan addressing con- gaps, but help policymakers and providers understand tinuity of care for patients as well as plans to support how and why patients are using, or not using, the health laid-off staff, giving the city more leverage to ensure system. In our own work, neighborhood residents and equitable distribution of care [54]. Researchers and health care workers (who are often both users and pro- policymakers might investigate the short and long-term viders of care in their neighborhoods) are essential key effects of similar policies through a health care gentri- informants. fication lens. Finally, at the organizational level, private health sys- Health care gentrification research must also examine tems also play an important role in meeting the needs solutions of all residents, not just the most profitable, as anchors In addition to understanding the multi-level drivers of of neighborhoods and communities. This includes health care gentrification and its interplay with other ensuring health care access, working toward address- urban processes such as neighborhood gentrification, ing social determinants of health, such as housing and applied research should also focus on finding solutions to quality jobs, and partnering with public providers and reduce and mitigate the impact of health care gentrifica- state and local governments. For instance, some sys- tion, as Thomas et al. describe in their call for a rigorous, tems are working on local hiring and procurement action-oriented generation of health equity research [51]. initiatives to support residents beyond direct health Across the U.S, there are promising avenues and policy services (i.e., www.​healt​hcare​anchor.​netwo​rk/). These levers worthy of further study. measures could have significant impacts on health and First, federal and state government can use their regu- well-being, since health care facilities have long been a latory power to incentivize providers to increase access local source of stable, middle-class and often unionized for marginalized communities. At the federal level, the jobs. Centers for Medicaid and Medicare Services sets Medi- At a broader scale and highlighting the interdiscipli- care payments and sponsors new payment models, inno- nary nature of health care gentrification, the impacts of vation grants and waivers for states such as Medicaid planning agendas that employ health promotion rheto- Accountable Health Communities [52]. At the state level, ric such as Healthy Cities and Health in All Policies, or states can use their authority over Medicaid design and promote sustainable and resilient cities using a health payment, licensing, regulation, scope of practice and motive, should be considered. These trends in policy enforcement of the community benefits non-profit sys- tend to under-emphasize the role of health care itself tems are required to provide to drive the allocation of arguing that population health is more influenced by health care resources where they are most needed [50]. other aspects of the environment. But this approach While cities may lack the regulatory control of the ignores the fact that health care, while not sufficient, is state and federal government, many are exploring local necessary for maintaining population health, particu- policies and programs to prevent or control gentrifica- larly considering the needs of chronically ill, elderly, tion. Such efforts require collaboration between federal, people with disabilities, or pregnant people, among state and local policymakers, and public and private others. Ensuring equitable access to quality health care sectors but can also put more control over services in should thus be purposefully placed within urban plan- ning agendas intended to improve health. Cole and Franzosa International Journal for Equity in Health (2022) 21:66 Page 9 of 10 Conclusions Received: 24 October 2021 Accepted: 20 April 2022 Published: 11 May 2022 Ensuring equitable access to health care is a timely con- cern as the capacity of health care systems has been called into question during the COVID-19 pandemic. References Inequitable access to and use of testing, treatment, 1. Gooch K. Pennsylvania hospitals see boost in ER visits, admissions amid and vaccination have been evident between and within Hahnemann closure. 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A • thorough peer review by experienced researchers in your field Re-conceptualization of access for 21st Century Healthcare. J Gen Intern • rapid publication on acceptance Med. 2011;26(Suppl 2):639. https://​doi.​org/​10.​1007/​S11606-​011-​1806-6. • support for research data, including large and complex data types 41. Ricketts TC, Goldsmith LJ. Access in health services research: The battle of the frameworks. Nurs Outlook. 2005;53(6):274–80. https://​doi.​org/​10.​ • gold Open Access which fosters wider collaboration and increased citations 1016/j.​outlo​ok.​2005.​06.​007. • maximum visibility for your research: over 100M website views per year 42. Cyr ME, Etchin AG, Guthrie BJ, Benneyan JC. Access to specialty healthcare in urban versus rural US populations: A systematic literature At BMC, research is always in progress. review. BMC Health Serv Res. 2019;19(1):974. https://​doi.​org/​10.​1186/​ s12913-​019-​4815-5. Learn more biomedcentral.com/submissions