Doctor Demographics
Doctor Demographics
I write about where to put a practice, the market conditions that are influencing the places where dentistry works best, and the trends that are helping or inhibiting practice.
Blog By:
Mike Green
Mike Green

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Kiss of Death Locations 2027

Kiss of Death Locations 2027

10/13/2026 3:28:00 PM   |   Comments: 0   |   Views: 36
Kiss of Death Locations for 2027: Click here for full episode: https://doctordemographics.com/podcast


Kiss of Death Locations 2027

Episode Transcript:

Welcome to The Perfect Place to Put a Practice podcast. I’m your host, Mike Green, from Doctor Demographics. Today is the annual episode a lot of you wait for, and a few of you dread: Kiss of Death locations for 2027.

Alright. Let’s set the rules.

This year’s list is five mid-size and large cities. Not tiny Rust Belt towns. These are places a doctor can picture themselves living. Nice restaurants. A skyline. A story you can tell your spouse. That is exactly why they are dangerous. The postcard is not the pro forma.

Every year I make the same disclaimer, and I am making it again. Landing on this list does not mean you cannot succeed. Over the years we have put doctors in beautiful demographic pockets and watched them struggle because they ignored reputation, staff, and follow-up. We have also watched doctors walk into markets we would not have chosen and build something remarkable, because they were exceptional operators. Demographics are not destiny. They are the wind. You still have to sail.

So what earns a city the kiss of death in 2027? Three things, usually stacked.

First, the patient base is not growing the way your loan assumes it will. People are leaving, aging in place without new families behind them, or splitting their spending between a city office and a suburb you do not own.

Second, the government and the cost structure are not on your side. The Tax Foundation’s 2026 State Tax Competitiveness Index puts New York, New Jersey, and California at the bottom of the country. New York is 50th, New Jersey 49th, California 48th. High income taxes, high corporate taxes, high property taxes, and slow permitting all show up in your overhead before you see patient one.

Third, you are not the only one who had the idea. Nationally there are about 59.5 dentists per 100,000 people. California is around 76.6. New York is around 71. Hawaii is around 78. Washington, D.C., which we are not ranking today, is over 100. A famous city can be a shortage area in one neighborhood and a knife fight in the next.

We are counting down from five to one. After each city, one upside. Because if you are already under contract, you need a plan, not a lecture.

Number five: Honolulu, Hawaii.

Honolulu is the new name on this year’s list, and it earns the spot for a simple reason. The island is a closed system with a very expensive door.

Hawaii sits among the least competitive tax climates in the country. The cost of living is among the highest in the United States. Commercial rent, housing for your associate, and wages for hygienists, technicians, and vet techs all clear a bar that a mainland startup does not have to clear. Clarify Capital’s recent look at cities for dentists put Honolulu in the bottom ten, and that lines up with what we see on the ground. You cannot recruit your way out of a bad week by hiring someone from the next county. The next county is an ocean.

Tourism makes the economy look busy and the appointment book look fragile. A slow season, a cancelled flight week, or a soft year for visitors hits elective dentistry, refractive plans, and wellness veterinary visits harder than people expect. Local families are real patients. They are also price-sensitive once rent and groceries take the first bite of the paycheck. Fee-for-service cosmetic work is a smaller slice of the market than the brochure suggests.

The upside: if you are already rooted there, the moat runs both ways. New competitors hate the same costs you hate. A practice with military, university, and long-time local relationships can be remarkably sticky. The play is not “be the new office in Waikiki.” The play is a specific neighborhood, a specific payer mix, and a staff you can actually house.

Number four: Baltimore, Maryland.

Baltimore is mid-size to large, and it has been on this list before because the trend did not turn. The city population has been sliding, down into the mid-500,000s, while families who can choose often choose the surrounding counties. Crime still shapes where staff will work a late shift and where patients will park. Maryland is in the bottom tier of that same Tax Foundation index. Baltimore’s own property-tax load is heavy for a city trying to refill vacant blocks.

For a new practice, the trap is the split market. Downtown and the harbor can look renewed on a Saturday. A Tuesday in a transitional neighborhood is a different business. Insurance mix is uneven. Uninsured and Medicaid-heavy pockets sit next to insured professional pockets, and a startup that guesses wrong on which one it bought spends the first two years rewriting its fees. Veterinarians feel this as deferred wellness care. Optometrists feel it as patients who need the exam and delay the glasses. Dentists feel it as a schedule full of emergencies and thin on crowns.

The upside: Johns Hopkins and the broader medical corridor are not a myth. Referral relationships, faculty families, and underserved neighborhoods that truly lack a stable private office are real. The doctors who make Baltimore work usually do not try to be everything to the whole city. They pick a ZIP code, a hospital relationship, or a suburb just outside the line, and they stay there long enough to become the default.

Number three: Portland, Oregon.

Portland is the city that looks like it should work for a health practice and then quietly does not, at least not for a brand-new office in the core.

The city proper has been soft since 2020. Homelessness, downtown retail vacancy, and a business exodus are not talking points. They are reasons a parent reschedules and a front-desk hire quits. Oregon’s tax structure is the other half. No sales tax sounds friendly until you meet the income tax, and staff wages have to clear a high cost of living. Permitting and local process are not fast. A startup burning rent during a build-out feels that every month.

The clinical demand is there in the abstract. Portland patients like prevention, they like explanation, and they will pay for a relationship. The problem is where they will drive. A lot of the stable household growth is in Beaverton, Lake Oswego, Hillsboro, and Vancouver across the river, not in the postcard blocks. Open in the wrong pocket and you are marketing against perception as much as against the office down the street.

The upside: that wellness culture is an asset if you locate for it. An optometrist with a medical-eye story, a dentist who is serious about anxiety and long visits, a veterinarian who builds a membership plan, can do well on the west side or in a close-in suburb. Portland punishes a generic lease in a struggling retail strip. It does not punish a clear niche and a parking lot.

Number two: Chicago, Illinois.

Chicago is the large-market version of the same warning. The city is still enormous. Enormous is not the same as easy.

Population in the city has been drifting down, and a lot of the households a private practice wants are already in the suburbs. Illinois property taxes and pension pressure show up in commercial rent, in your home, and in your employees’ decisions about whether to stay. Licensing and hiring are slower and more rule-bound than in the markets we usually like for a first office. Provider supply is deep. You are not discovering dentistry, optometry, or veterinary care for this region. You are asking people to switch.

Office vacancy downtown is high enough that landlords will tell you space is a bargain. Sometimes the bargain is a floor plate nobody wants to visit after 5 p.m. Patient retention gets harder when the patient works hybrid and lives in Naperville. Your recall system is now competing with a commute.

The upside: Chicago still concentrates income, universities, and specialists in a way few cities can match. A practice tied to a specific ethnic corridor, a specific campus, or a near suburb with a real daytime population can be busy. The kiss of death is a generic startup in a soft neighborhood because the rent looked low. The survival path is a site selection that assumes the patient already has three other options and needs a reason to pick you.

Number one: San Francisco, California.

San Francisco stays at the top of the 2027 list. Not because it is a bad city. Because it is a brutal spreadsheet.

The city is still well below its pre-2020 population after a drop on the order of 7 percent, into the low 800,000s. Remote work did not fully reverse. Housing costs did not become reasonable. California is 48th on the Tax Foundation index, with a top marginal income-tax rate of 13.3 percent before payroll taxes are layered on. Commercial rent, build-out, and staff housing sit on top of that. WalletHub’s recent large-city rankings keep putting San Francisco, San Jose, and other Bay Area cities near the bottom for starting a business. The pattern is consistent. Costs up, process slow, margin thin.

The market is also split in a way that fools new owners. Affluent patients are real, and they are picky. They already have a dentist, an ophthalmologist, and a veterinary hospital. The other half of the city cannot carry a fee schedule built for Pacific Heights. Corporate and multi-location offices already own a lot of the convenient corners. A 2025 startup that needs 18 months of ramp-up is paying San Francisco burn against a patient who may leave for Oakland, the Peninsula, or another state before the second recall.

The upside, and it is a real one: density of income and a shortage of patience for mediocre care. If you buy an existing practice with a transferable reputation, or you open inside a micro-neighborhood where you already live and already know the building owner, San Francisco can throw off strong production per visit. The fatal version is a cold start, a market-rate lease, and a marketing plan that says “best dentist in San Francisco.” Nobody is shopping for that. They are shopping for the person three blocks away who called them back.

So that is the 2027 list. Honolulu. Baltimore. Portland. Chicago. San Francisco.

The thread through all five is not vibes. It is math. A shrinking or stalled local demand pool. An overhead structure that assumes you are already successful. And enough existing providers that “we just opened” is not a marketing strategy.

If you are looking at one of these cities anyway, do three things before you sign. Get the household trend for the specific ZIP codes, not the metro brochure. Get the provider count and the insurance mix within a ten-minute drive. And get a build-out and wage budget that still works if revenue is 20 percent light in year one. That last test knocks out more pretty cities than any ranking I can read on a podcast.

If you want a second set of eyes on a site, that is the work we do. Visit doctordemographics.com, or call (844) 704-0499.

Thanks again for more than 300 episodes of support. Tell a colleague who is about to fall in love with a skyline. I’m Mike Green. We’ll see you on the next episode of The Perfect Place to Put a Practice.






Category: Marketing, Practice Transitions
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