United States Government Accountability Office

GAO Report to Congressional Committees

HEALTH 

PROFESSIONAL 

SHORTAGE AREAS 

Problems Remain with 

Primary Care Shortage 

Area Designation 

System 

October 2006 

 

GAO-07-84 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

October 2006

HEALTH PROFESSIONAL SHORTAGE 

AREAS 

Problems Remain with Primary Care 

Shortage Area Designation System 

Highlights of GAO-07-84, a report to 

congressional committees 

To identify areas facing shortages 

of health care providers, HHS relies

on its health professional shortage 

area (HPSA) designation system.

HHS designates geographic, 

population-group, and facility 

HPSAs. HHS also gives each HPSA 

a score to rank its need for 

providers relative to other HPSAs.

The Health Care Safety Net

Amendments of 2002 required GAO 

to report on the HPSA designation 

system. GAO reviewed (1) the 

number and location of HPSAs and 

federal programs that use HPSA 

designations to allocate resources

or provide benefits, (2) available 

research on HPSA designation 

criteria and methodology, and 

(3) the impact of a 2002 provision 

that automatically designates

federally qualified health centers 

and certain rural health clinics as

facility HPSAs. GAO obtained and 

analyzed HHS’s data on primary 

care HPSA designations as of 

September 2005 and January 2006

and identified reports on HPSA 

criteria and methodology through a 

literature search of peer-reviewed 

journals and other reports 

published since 1995. 

What GAO Recommends

GAO recommends that HHS 

(1) remove the designations of 

HPSAs that no longer qualify by

publishing a list of designated 

HPSAs in the Federal Register and

(2) complete and publish HHS’s 

proposal to revise the HPSA

designation system. HHS concurred 

with both recommendations. 

GAO identified more than 5,500 HPSAs designated throughout the United 

States as of September 2005; multiple federal programs relied on these 

designations to allocate resources or provide benefits. GAO estimated that 

slightly more than half of the HPSAs were designated for geographic areas, 

such as counties or portions of counties, or population groups, such as 

migrant farmworkers. The remaining HPSAs were designated for facilities, 

such as rural health clinics. In fiscal year 2005, more than 30 federal 

programs relied on HPSA designations, and in some cases HPSA scores, to 

allocate resources or provide benefits. The use of the HPSA designation by 

numerous federal programs to allocate resources or provide benefits is an 

incentive for obtaining and retaining a HPSA designation. 

Published reports have pointed to shortcomings in the methodology used for 

designating HPSAs. These reports’ observations were consistent with 

findings in GAO’s 1995 report, Health Care Shortage Areas: Designations 

Not a Useful Tool for Directing Resources to the Underserved, (GAO/HEHS95-200, Sept. 8, 1995), including that HHS’s methodology did not account for 

certain types of primary care providers already serving in a HPSA, which can 

result in an overstatement of the provider shortage. Recognizing the 

shortcomings of the current methodology, HHS has been working since 1998 

on a proposal to revise the designation system. In addition, some HPSAs that

no longer meet the criteria have retained their HPSA designation and 

possibly received benefits from federal programs that rely on that 

designation. HHS has not complied since 2002 with the statutory 

requirement to annually publish a list of designated HPSAs in the Federal 

Register—which would remove the designations of those HPSAs that are no 

longer listed. 

Many federally qualified health centers and rural health clinics did not 

benefit from automatic designation as facility HPSAs because they were 

located in geographic or population-group HPSAs. In addition, most of the 

more than 1,600 federally qualified health centers received HPSA scores

associated with the automatic designation that were too low to qualify them 

for certain federal programs that required a minimum HPSA score in 2005,

although they qualified for other programs that did not have such a 

requirement. Of the 590 rural health clinics that chose to certify that they 

would treat anyone regardless of ability to pay and, as a result, received 

automatic designation as facility HPSAs, most also received associated 

HPSA scores too low to qualify for benefits from certain federal programs 

that required a higher HPSA score. 

www.gao.gov/cgi-bin/getrpt?GAO-07-84.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Leslie G. 

Aronovitz at (312) 220-7600 or 

aronovitzl@gao.gov. 
Contents 

Letter 1

Results in Brief 5

Background 8

HPSAs Are Located in Every State and Are Used by Multiple 

Federal Programs 14 

Research Points to Shortcomings with Designation Methodology 25 

Many Health Centers and Rural Health Clinics Did Not Benefit 

from Automatic HPSA Designation 29 

Conclusions 34

Recommendations for Executive Action 35 

Agency Comments 35 

Appendix I Scoring of Health Professional Shortage Areas 38 

Appendix II Medically Underserved Area or Population 

Designations and Medically Underserved 

Community Definition 41 

Appendix III Scope and Methodology 45 

Appendix IV Federal Programs Using Health Professional 

Shortage Area and Other Designations of 

Underservice 49 

Appendix V Comments from the Department of Health and 

Human Services 55 

Appendix VI GAO Contact and Staff Acknowledgments 59 

Page i GAO-07-84 Health Professional Shortage Areas
Related GAO Products 60 

Tables 

Table 1: Number of, Population in, and Physicians Needed in

Geographic and Population-Group HPSAs, September 2005 15 

Table 2: Programs and Administering Agencies That Used HPSA, 

MUA, MUP or Other Designations to Allocate Resources or 

Provide Benefits in Fiscal Year 2005 49 

Figures 

Figure 1: HPSA Designation Request and Review Process, 2005 9 

Figure 2: Types of HPSAs and Criteria Used to Designate Them, 

2005 10

Figure 3: U.S. Counties with Geographic and Population-Group 

HPSAs, January 2006 16 

Figure 4: Types of Facility HPSAs, September 2005 19 

Figure 5: Distribution of HPSA Scores among Health Centers 

Automatically Designated as Facility HPSAs, September 

2005 31

Figure 6: Distribution of HPSA Scores among Rural Health Clinics 

Automatically Designated as Facility HPSAs, September 

2005 34

Figure 7: Scoring of HPSAs, 2005 39 

Page ii GAO-07-84 Health Professional Shortage Areas
Abbreviations 

CMS Centers for Medicare & Medicaid Services 

COGME Council on Graduate Medical Education 

HHS Department of Health and Human Services 

HPSA health professional shortage area

HRSA Health Resources and Services Administration 

IHS Indian Health Service 

MUA medically underserved area 

MUP medically underserved population 

NHSC National Health Service Corps 

USCIS U.S. Citizenship and Immigration Services 

VA Department of Veterans Affairs 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. It may be reproduced and distributed in its entirety without further 

permission from GAO. However, because this work may contain copyrighted images or 

other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 

Page iii GAO-07-84 Health Professional Shortage Areas
United States Government Accountability Office

Washington, DC 20548 

October 24, 2006 

The Honorable Michael B. Enzi 

Chairman 

The Honorable Edward M. Kennedy 

Ranking Minority Member 

Committee on Health, Education, Labor, 

 and Pensions 

United States Senate 

The Honorable Richard Burr 

Chairman 

Subcommittee on Bioterrorism and Public 

 Health Preparedness 

Committee on Health, Education, Labor, 

 and Pensions 

United States Senate 

The Honorable Joe Barton 

Chairman 

The Honorable John D. Dingell 

Ranking Minority Member 

Committee on Energy and Commerce 

House of Representatives 

Many Americans live in areas, such as inner-city neighborhoods or isolated 

rural locations, where obtaining health care is difficult because health care 

providers are in short supply. To identify areas facing a critical shortage of 

providers, the Department of Health and Human Services (HHS) relies on 

its health professional shortage area (HPSA) designation system.1

Originally created in 1978 to identify areas in need of physicians and other

health care providers from HHS’s National Health Service Corps (NHSC) 

programs, HPSA designation is now used by a variety of federal 

programs—including programs that provide grants for health professions 

 1

Throughout this report, we use the term HPSA to denote health professional shortage 

areas for primary care, which HHS considers to include medical specialties of general or 

family practice, general internal medicine, pediatrics, and obstetrics and gynecology. In 

addition to primary care HPSAs, HHS designates HPSAs for fields other than primary care,

including dental and mental health. 

Page 1 GAO-07-84 Health Professional Shortage Areas
education and training or bonus payments under Medicare for physician 

services—to allocate resources or provide benefits.2

A HPSA can be a distinct geographic area (such as a county), a specific 

population group within an area (such as low-income individuals), or a 

specific health care facility. Facility HPSAs include federal or state 

correctional institutions, as well as federally qualified health centers—

facilities that provide primary care services in underserved areas3

—and 

certain rural health clinics—facilities that provide outpatient primary care 

services in rural areas.4

 HHS’s Health Resources and Services 

Administration (HRSA)—the HHS agency that manages the HPSA 

designation system—designates HPSAs based on the ratio of population to

the number of primary care physicians and other factors.5

 HRSA then 

 2

HPSAs can be located in all states and the District of Columbia, as well as in American 

Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of 

Micronesia, Guam, Puerto Rico, the Republic of the Marshall Islands, the Republic of Palau,

and the U.S. Virgin Islands. 

3

Federally qualified health centers, referred to as health centers in this report, include 

(1) health centers that receive a grant or funding from a grant under the consolidated 

health center program authorized under section 330 of the Public Health Service Act; 

(2) facilities, called look-alikes, that are determined by the Secretary of Health and Human 

Services to meet the requirements for receiving such a grant; and (3) outpatient health 

programs or facilities operated by a tribe or tribal organization under the Indian SelfDetermination Act or by an urban Indian organization receiving funds under title V of the 

Indian Health Care Improvement Act. Health centers are located in both urban and rural 

areas and are required to treat everyone regardless of ability to pay. According to data from

HHS’s Health Resources and Services Administration (HRSA), the agency that administers

the consolidated health center program and certifies look-alikes, there were over 1,600

health centers as of September 2005. 

4

Rural health clinics are located in rural areas and, unlike health centers, are not required 

to provide services to all individuals, regardless of their ability to pay. According to data

from HHS’s Centers for Medicare & Medicaid Services (CMS), the agency that certifies 

these clinics as rural health clinics for purposes of the Medicare and Medicaid programs,

there were over 3,600 rural health clinics as of September 2005.

5

In addition to the ratio of population to primary care physicians, HPSA designation is

based on other factors, such as health care resources available in neighboring areas. For 

those geographic HPSAs that have their HPSA designations on the basis of having 

unusually high needs for primary care services, the HPSA designations are also based on at 

least one of three other factors: the area’s infant mortality rate, the percentage of the 

population with incomes below the poverty level, or the area’s birth rate. See HRSA, 

Bureau of Health Professions, “Health Professional Shortage Area Primary Medical Care 

Designation Criteria,” http://bhpr.hrsa.gov/shortage/hpsacritpcm.htm (downloaded

May 15, 2006). HRSA also automatically designates health centers and certain rural health 

clinics as facility HPSAs; these facilities are not required to meet a ratio of population to

primary care physicians for HPSA designation. 

Page 2 GAO-07-84 Health Professional Shortage Areas
assigns each HPSA a score on the basis of specific criteria that ranks its 

shortage of primary care providers, or need, relative to other HPSAs.6

Some federal health care programs, such as NHSC programs, allocate their 

resources on the basis of HPSA scores, not just HPSA designations. 

HHS’s criteria and methodology for designating HPSAs has remained 

unchanged since October 1, 1993.7

 In 1998, in an effort to improve the way

underserved areas were designated, HHS published a proposal to revise 

the HPSA designation system.8

 The department received more than 800 

comments on its proposal from individuals and organizations, including 

individual physicians, state primary care organizations, and university or 

research organizations. These comments raised several issues, such as 

whether or how to count nonphysician providers, such as physician 

assistants, in the total number of practitioners serving a population; the 

potential number of HPSAs that would lose their HPSA designations 

because of changes in the designation criteria; and the incorporation of 

certain population factors, such as the percentage of elderly and uninsured 

individuals, which reflect a population’s ability to access care. In response 

to these comments, HHS withdrew its 1998 proposal, and left the existing

HPSA designation system in place while it began working on another 

proposal. 

The Health Care Safety Net Amendments of 2002 required that we report 

on the HPSA designation system and on a provision included in the act

that automatically designates health centers and certain rural health 

 6

Four factors, including factors used for HPSA designation, determine a HPSA’s score—

ratio of population to primary care physicians, percentage of the population with incomes

below the poverty level, infant mortality rate or low birth weight rate, and time or distance 

to the nearest source of primary care. Each HPSA is scored on a scale of 0 to 25, with

higher scores indicating greater relative need for primary care providers. See appendix I for 

additional information on HPSA scoring. 

7

Since 1995 we have reported on shortcomings of the HPSA designation system. See GAO,

Health Care Shortage Areas: Designations Not a Useful Tool for Directing Resources to

the Underserved, GAO/HEHS-95-200 (Washington, D.C.: Sept. 8, 1995), as well as “Related 

GAO Products” at the end of this report. 

8

63 Fed. Reg. 46538–55 (Sept. 1, 1998). The proposal included provisions to combine the 

HPSA designation system with HRSA’s other designations of underservice: the medically 

underserved area (MUA) and medically underserved population (MUP) designations. See 

appendix II for more information on the MUA and MUP designations. 

Page 3 GAO-07-84 Health Professional Shortage Areas
clinics as facility HPSAs.9

 As discussed with the committees of

jurisdiction, this report discusses (1) the number and location of HPSAs 

and the federal programs that use HPSA designations to allocate resources 

or provide benefits, (2) available research on the criteria and methodology 

used to designate HPSAs, and (3) the impact of the automatic HPSA 

designation on health centers and rural health clinics. 

To conduct our work, we examined relevant laws, regulations, and HHS 

documents related to the HPSA criteria in effect in 2005—criteria that had

remained unchanged since 1993—and reviewed our prior work on the 

HPSA designation system. To determine the number of HPSAs, we 

interviewed officials from HRSA, who reported that precise, accurate, 

historical data on the total number of HPSAs were not available. 

Therefore, to estimate the number of HPSAs designated as of September 

2005, we designed a methodology that used data from HRSA, including 

summary statistics on geographic and population-group HPSA 

designations and data files on the facilities that were automatically 

designated as HPSAs. We also analyzed a more detailed database of 

geographic and population-group HPSAs as of January 2006 in order to 

identify (1) the counties in which geographic and population-group HPSAs 

were located and (2) the HPSAs that were proposed for having their 

designations withdrawn because they no longer met the criteria or did not 

provide updated data in support of their designations. After taking steps to

eliminate potential duplications or inconsistencies in the data we used, we 

determined that the data were sufficiently reliable for our purposes. To 

obtain information on HPSA designations and federal programs that use 

HPSA designations, we reviewed Federal Register notices and other 

documents obtained from HHS agencies—including HRSA, the Centers for 

Medicare & Medicaid Services (CMS), and the Indian Health Service 

(IHS)—and reviewed our prior work on these programs. 

To identify available research on the criteria and methodology used to 

designate HPSAs, we conducted a literature search of reports, including 

those published in peer-reviewed journals, issued from January 1, 1995, 

through November 1, 2005. We identified other published reports 

discussing the HPSA designation methodology, including one by the 

Council on Graduate Medical Education (COGME). Of the more than 340 

 9

Pub. L. No. 107-251, § 302(a)(1)(A), (e); 116 Stat. 1621, 1643–1645. Under this act, health 

centers and those rural health clinics certifying that they serve all individuals, regardless of 

ability to pay, automatically receive designation as facility HPSAs. 

Page 4 GAO-07-84 Health Professional Shortage Areas
articles, studies, and reports—which we refer to as reports—identified in 

the search, we identified 7 that addressed the relationship between key 

elements of the HPSA designation criteria, such as income, and primary 

care physician supply or shortages, or that addressed factors related to the 

HPSA designation methodology. We also interviewed researchers who 

have studied primary care provider shortages, as well as HRSA officials 

knowledgeable about the HPSA designation system. To review the impact 

of the automatic designation on health centers and rural health clinics, we

analyzed HRSA’s data on automatic HPSA designations, including the 

HPSA scores associated with automatic designation, and interviewed 

HRSA officials and officials from associations representing these types of

facilities. We performed our work from August 2005 through September 

2006 in accordance with generally accepted government auditing 

standards.10

We identified more than 5,500 HPSAs designated throughout the United 

States as of September 2005; multiple federal programs relied on these 

designations to allocate resources or provide benefits. We estimated that 

slightly more than half of the HPSAs were designated for geographic areas

or population groups, and these geographic and population-group HPSAs 

were located in all 50 states and the District of Columbia. Facility HPSAs, 

which accounted for slightly less than half of the total number of HPSAs, 

were also located in every state and the District of Columbia. In fiscal year 

2005, more than 30 federal programs—including programs administered by 

HRSA, CMS, and federal agencies outside of HHS—relied on HPSA 

designations and, in some cases, HPSA scores, to allocate resources or 

provide benefits. These included NHSC programs that award scholarships 

or educational loan repayment to students and health professionals in 

exchange for a commitment to practice in HPSAs for at least 2 years. 

Other programs relying on HPSA designations to allocate resources or 

provide benefits included programs that pay physicians bonus payments 

for services provided to Medicare beneficiaries in geographic HPSAs and 

programs that waive certain requirements for foreign physicians if they 

agree to practice in HPSAs or other underserved areas of the United 

States. The use of the HPSA designation by numerous federal programs to 

allocate resources or provide benefits is an incentive for obtaining and 

retaining a HPSA designation. 

Results in Brief 

 10See appendix III for additional information on our scope and methodology. 

Page 5 GAO-07-84 Health Professional Shortage Areas
Of the seven reports we identified that discuss the criteria and 

methodology used to designate HPSAs, one supported a relationship 

between a key element of the HPSA criteria and primary care physician 

supply, while the remaining six pointed to shortcomings in the 

methodology. The one report we identified that supported a key element 

of the criteria found that areas with higher incomes had more primary care 

physicians than areas with lower incomes. The other six reports included 

observations that were consistent with what we reported in 1995, 

including the fact that the HPSA designation methodology does not 

account for the presence of certain types of primary care providers in a 

HPSA, which can result in an overstatement of the shortage of primary 

care providers. Researchers have highlighted other problems in the 

methodology used to designate HPSAs, such as relying on geographic 

boundaries that do not necessarily reflect areas’ health care needs. 

Recognizing the shortcomings of the current methodology, HHS has been

working since 1998 on a proposal to revise the HPSA designation system, 

which, as of September 2006, was in the department’s clearance process. 

In 1995, we reported on an additional problem involving the timeliness 

with which HRSA identified and removed the HPSA designations of those 

areas, population groups, and facilities that no longer met the HPSA 

criteria—a problem that has continued in recent years. For example, in 

2005, the HHS Office of Inspector General reported that, as of 2003, HRSA 

had not reviewed HPSA designations in a timely manner. In addition, we 

found that since 2002, HHS has not complied with the statutory 

requirement to annually publish a list of designated HPSAs in the Federal 

Register or otherwise remove the HPSA designations for those HPSAs that 

either no longer meet the criteria or have not provided updated data in 

support of their designations. As a result, some HPSAs that no longer meet 

the criteria have retained their HPSA designations and possibly received 

benefits from federal programs that rely on the designation for allocating

resources. 

Automatic HPSA designation of health centers and certain rural health

clinics as facility HPSAs provided little or no benefit for many of these 

facilities. For health centers and rural health clinics located in geographic 

or population-group HPSAs before implementation of the 2002 provision, 

automatic designation as a facility HPSA resulted in no added benefit 

unless the HPSA score associated with the automatic designation was 

higher than the score for the geographic or population-group HPSA in 

which the facility was located. Although precise data were not available, 

HRSA officials estimated that many of the more than 1,600 health 

centers—all of which received automatic designation as facility HPSAs—

were located in geographic or population-group HPSAs before 2002. Of the 

Page 6 GAO-07-84 Health Professional Shortage Areas
more than 3,600 rural health clinics, 590 had certified they would treat 

everyone regardless of ability to pay and, as a result, received automatic 

HPSA designation as of September 2005; however, data were not available 

to determine how many of them were located in geographic or populationgroup HPSAs before receiving automatic HPSA designation. In addition, 

although officials that work with health centers and rural health clinics 

reported that these facilities in general welcomed the automatic HPSA 

designation because it could allow them the benefit of recruiting a 

physician through the NHSC, few had HPSA scores associated with the 

automatic designation that were high enough to qualify for a physician 

through the NHSC Scholarship Program. Specifically, as of September 

2005, less than 5 percent of the health centers and less than 1 percent of 

the rural health clinics with automatic facility HPSA designations had 

HPSA scores that were high enough to qualify for a physician through the

NHSC Scholarship Program. However, all health centers and rural health 

clinics that received automatic designations as HPSAs, even those with 

lower HPSA scores, could apply in 2005 for a health care provider through 

another NHSC program, the NHSC Loan Repayment Program. 

We are recommending that HHS (1) publish a list of designated HPSAs in 

the Federal Register or otherwise remove, through Federal Register

notification, the HPSA designations for those HPSAs that no longer meet 

the criteria or have not provided updated data demonstrating they still 

meet the designation criteria and (2) complete and publish HHS’s proposal 

to revise the HPSA designation system and address the problems that have 

been identified in the current methodology for designating HPSAs. 

In commenting on a draft of this report, HHS concurred with our 

recommendations. Specifically, the department agreed that more timely 

publication of a list of designated HPSAs in the Federal Register is 

necessary, noting that publication in the Federal Register ensures that 

those HPSAs that have been proposed for withdrawal have their 

designations removed. The department also agreed with our 

recommendation to complete and publish its proposal to revise its HPSA 

designation system, stating that its proposal would address the various 

shortcomings that we have identified in this and previous reports. 

Page 7 GAO-07-84 Health Professional Shortage Areas
Background Any agency or individual may request a HPSA designation for a geographic 

area, population group, or facility.11 According to HRSA officials, the vast 

majority of HPSA designation requests are submitted by state primary care 

offices.12 These requests are received and reviewed by the Shortage 

Designation Branch within HRSA. Individual and agency requesters, other 

than state primary care offices, are required to submit a copy of their 

request for HPSA designation to their state’s primary care office. The state 

primary care office solicits comments about the request from state groups, 

including the state health department and state professional associations, 

and forwards the comments to HRSA. Other interested parties may also 

provide comments on the request and submit the comments directly to 

HRSA. HRSA’s final designation decision is based on a review of the 

request and comments received from the state and other interested parties 

(see fig. 1). 

 11HPSA designations may be requested for geographic areas, population groups, and 

facilities located in all states and the District of Columbia, as well as in American Samoa, 

the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, 

Guam, Puerto Rico, the Republic of the Marshall Islands, the Republic of Palau, and the 

U.S. Virgin Islands. The HPSA request and review process is the same for all locations. 

12State primary care offices work toward addressing the needs of the medically 

underserved in their states and receive funding through HRSA grants and cooperative 

agreements. For more information, see HRSA, Bureau of Primary Health Care, “Directory 

of Primary Care Offices (PCO): December 2005,” 

http://bphc.hrsa.gov/OSNP/PCODirectory.htm (downloaded June 19, 2006). 

Page 8 GAO-07-84 Health Professional Shortage Areas
Figure 1: HPSA Designation Request and Review Process, 2005 

State primary care office solicits

comments on HPSA designation request 

from state groups including:

• Governor’s office

• State health planning and development 

agency or state health department

• State or regional primary care

associationa

• State professional associations

• Health systems agency

Other interested parties may also provide 

comments.

All parties have 30 days to review

HPSA designation request and submit 

comments to HRSA, either directly or 

through the state primary care office.

HRSA reviews HPSA designation request 

and comments. HRSA makes a decision 

on HPSA designation and notifies the 

requester and other interested parties.

Agency or individual submits HPSA designation request to HRSA and, if the requesting agency is

not the state primary care office, submits a copy of the request to the state primary care office.

Source: GAO analysis of relevant statutes, regulations, and guidance.

a

Primary care associations are private, nonprofit organizations representing states or regions that 

provide training and technical assistance to facilities, including health centers, to help ensure that 

these facilities deliver high-quality primary care services in underserved communities. For more 

information, see HRSA, Bureau of Primary Health Care, “Directory of Primary Care Associations 

(PCA): April 2005,” http://bphc.hrsa.gov/OSNP/PCADirectory.htm (downloaded Apr. 3, 2006). 

HRSA designates three types of HPSAs: geographic, population-group, and 

facility. Geographic HPSAs include entire counties, a portion of a county,

or a group of contiguous counties. Population-group HPSAs include 

groups, such as migrant farmworkers, low-income urban populations, or 

federally recognized Native American Tribes or Alaska Natives, within a 

particular geographic area. Facility HPSAs include federal or state 

correctional institutions, health centers, and certain rural health clinics. 

To receive HPSA designation, the requesting agency or individual must 

provide HRSA with information demonstrating that the area, population 

group, or facility meets applicable criteria (see fig. 2).13

 13See 42 C.F.R. pt. 5, apps. A–G (2005). 

Page 9 GAO-07-84 Health Professional Shortage Areas
Figure 2: Types of HPSAs and Criteria Used to Designate Them, 2005

Source: GAO analysis of relevant statutes, regulations, and guidance. 

First 

Second 

Third 

Fourth 

Fifth 

Criteria

● Must be a rational service area for the 

 delivery of primary medical care servicesa

● Ratio of population to primary care 

 physicians must be at least 3,500:1 

 (or less than 3,500:1 but greater than 3,000:1

under special circumstancesb)

● Provider resources in adjoining areas are

 overused, excessively distant, or otherwise

 inaccessible

Criteria

● Must live in a rational service area for the

 delivery of primary medical care servicesa

● Ratio of population group to primary care 

 physicians serving that group must be at 

 least 3,000:1

● Must face barriers, such as language or

 culture, limiting access to medical care

 providers

Criteria

Federal or state correctional institutions:

● Ratio each year of inmates to primary care physicians serving the facility must be at least 1,000:1

● Inmate population must be at least 250

Public or nonprofit medical facilities:

● Must provide primary medical care services to

a geographic or population-group HPSA

● No required population-to-physician ratio, but 

 facility's capacity must be too low to meet the

 primary care needs of the area or population

Health centers or rural health clinics:

● Must be federally designated health center

 or rural health clinic

● Rural health clinics must certify that they

 provide health care services to anyone, 

 regardless of ability to pay

Facility HPSAs can include federal or state 

correctional institutions, health centers, and 

rural health clinics.

Population-group HPSAs can include migrant 

farmworkers, low-income populations, and 

federally recognized Native American Tribes 

or Alaska Natives.

Geographic HPSAs can include entire counties, 

a portion of a county, or a group of contiguous 

counties.

Geographic areas Population groups Facilities

Medical 

facility

Health 

center

Correctional

institution

Page 10 GAO-07-84 Health Professional Shortage Areas
a

HRSA defines a rational service area for the delivery of primary medical care services as (1) a 

county or group of contiguous counties whose population centers are within 30 minutes travel time of

each other; (2) a portion of a county, or an area made up of portions of more than one county, whose 

population, because of topography, market or transportation patterns, distinctive population 

characteristics, or other factors has limited access to contiguous area resources, as measured 

generally by a travel time greater than 30 minutes to such resources; or (3) established 

neighborhoods and communities within metropolitan areas that display a strong self-identity (as 

indicated by a homogeneous socioeconomic or demographic structure or a tradition of interaction or

interdependency), have limited interaction with contiguous areas, and that, in general, have a 

minimum population of 20,000. 42 C.F.R. pt. 5, app. A, I B.1, II A.1.(a) (2005). 

b

Special circumstances exist in an area if it has unusually high needs for primary care services or an 

insufficient supply of primary care providers. Unusually high needs may be demonstrated if, for 

example, more than 20 percent of the population have incomes below the federal poverty level. 

Insufficient supply of providers may be demonstrated if, for example, the area has unusually long 

waits for appointments for routine medical services and at least two-thirds of the area’s physicians do 

not accept new patients. 42 C.F.R. pt. 5, app. A, I B.4., 5 (2005). 

Since 2002, two kinds of facilities—(1) health centers and (2) rural health

clinics that certify that they treat everyone regardless of ability to pay—

have been automatically designated as facility HPSAs without going 

through the standard request and review process.14 Health centers include 

consolidated health centers, health center look-alikes, and tribal health 

centers:15

• Consolidated Health Centers: These health centers—which include 

community health centers, migrant health centers, health centers for the 

homeless, and health centers for residents of public housing—receive 

grants and grant funding16 under section 330 of the Public Health Service 

Act. Consolidated health centers provide comprehensive communitybased primary care services to individuals regardless of their ability to pay 

and are required to serve the medically underserved.17

• Health center look-alikes: These facilities have been determined to meet 

all of the requirements necessary to receive a grant under section 330 of 

the Public Health Service Act but do not receive such funding.

 1442 U.S.C. §§ 254e(a)(1), 254g(a)(1), 1395x(aa)(2), (4). 

15Health centers are reimbursed under CMS’s Medicare and Medicaid programs using 

special payment mechanisms that serve as an incentive for becoming a health center. See 

also GAO, Health Centers and Rural Clinics: State and Federal Implementation Issues 

for Medicaid’s New Payment System, GAO-05-452 (Washington, D.C.: June 17, 2005).

16Some health centers receive grant funding from another entity that is the recipient of such

a grant. To be considered a health center, they must also be eligible to receive a grant 

directly. 

17A consolidated health center must serve an area or population designated by HHS as an

MUA or MUP. See appendix II for information on the MUA and MUP designations. 

Page 11 GAO-07-84 Health Professional Shortage Areas
• Tribal health centers: These facilities receive federal support to provide 

outpatient health services and are operated by tribes, tribal organizations, 

or urban Indian organizations under the Indian Self-Determination Act or 

the Indian Health Care Improvement Act. 

Rural health clinics are located in rural areas and can operate either 

independently or as part of a larger organization, such as a hospital, skilled 

nursing facility, or home health agency.18 Unlike health centers, which are 

public or private nonprofit facilities, rural health clinics may function as 

for-profit entities. Rural health clinics must offer primarily outpatient 

primary medical care, but unlike health centers, they are not required to 

serve all individuals regardless of their ability to pay. Therefore, those 

rural health clinics that wish to receive automatic facility HPSA 

designation must certify to HRSA that they provide services to all 

individuals, regardless of their ability to pay, in order to receive the 

designation.

After receiving the HPSA designation, each geographic, population-group, 

and facility HPSA is scored on a scale of 0 to 25, with higher scores 

indicating greater relative need for primary care providers. The HPSA 

score is based on four elements, including elements used for HPSA 

designation: the ratio of population to primary care physicians (1 to 5 

possible points, then doubled), poverty rate (0 to 5 possible points), infant 

mortality rate or low birth weight rate (0 to 5 possible points), and travel 

time or distance to the nearest available source of primary care (0 to 5 

possible points). For a health center or rural health clinic automatically 

designated as a facility HPSA, if complete data are not available or HRSA 

cannot match the facility to appropriate data to calculate a HPSA score, 

the HPSA receives either a score of 0 or a partial score based on the sum 

of factors for which data are obtainable.19 According to HRSA’s data on 

health centers and rural health clinics that received automatic designation 

as facility HPSAs, 10 percent of these facility HPSAs had a HPSA score of 0 

as of September 2005. 

 18Rural health clinics are reimbursed under CMS’s Medicare and Medicaid programs using 

special payment mechanisms that serve as an incentive for becoming a rural health clinic.

To be reimbursed under Medicare and Medicaid, a rural health clinic must be located in a

geographic or population-group HPSA in a rural area, a rural area designated by a state’s 

governor (or chief executive officer) and certified by HHS as an area with a shortage of

personal health services, or a rural area HRSA has designated as an MUA. See appendix II 

for additional information on the MUA designation. 

19See appendix I for additional information on the scoring of HPSAs.

Page 12 GAO-07-84 Health Professional Shortage Areas
HRSA calculates the HPSA score using the information from the HPSA 

designation request. For health centers and rural health clinics that receive

automatic facility HPSA designation, HRSA calculates the HPSA score 

using nationally available data and approximates the service area of a 

health center or rural health clinic by using data on the Primary Care 

Service Area in which the facility is located.20 Any automatically

designated facility HPSA located in a geographic or population-group 

HPSA may instead use the HPSA score for that geographic area or 

population group, which, according to HRSA officials, is likely to be much 

higher than the automatic facility HPSA score.21 According to HRSA 

officials, nationally available data used for automatic facility HPSA scores 

are often not as current or as precise as data collected for individual 

geographic and population-group HPSA designations. 

HHS is required by law to review HPSA designations annually to determine 

if the designations remain appropriate in light of the applicable

requirements.22 Each year, it must also publish a list of designated HPSAs 

in the Federal Register.

23 For HPSAs designated through the standard 

request and review process, HHS reviews the designations by giving a list 

of HPSAs that have been designated for 3 full years to each state and 

asking the relevant state groups—including the state’s governor’s office 

and state health department—to update the information. HPSA 

designations for which data are not provided or that no longer meet the 

designation criteria are proposed for withdrawal. A HPSA that is proposed 

for withdrawal remains designated as a HPSA until HHS publishes in the 

Federal Register either a notification that the HPSA designation has been 

withdrawn or an updated list of designated HPSAs that does not include 

 20A Primary Care Service Area is a zip code with one or more primary care providers or any 

contiguous zip codes whose Medicare populations seek the largest share of their primary 

care from those providers. For more information, see Center for Evaluative Clinical 

Sciences at Dartmouth, “The Primary Care Service Area Project,” 

http://www.dartmouth.edu/~cecs/pcsa/pcsa.html# (downloaded Jan. 31, 2006). 

21In addition, health centers that provide services at more than one delivery site receive a 

HPSA score for the entire entity, which is calculated by averaging the individual HPSA 

scores assigned to each site. If any individual site of a health center is in a geographic or

population-group HPSA or has been designated as a facility HPSA through the standard 

request and review process, the site may use that HPSA’s score for purposes of applying for

federal programs. 

2242 U.S.C. § 254e(d)(1); 42 C.F.R. § 5.4(b) (2005). 

2342 U.S.C. § 254e(d)(2). 

Page 13 GAO-07-84 Health Professional Shortage Areas
that HPSA.24 Before a HPSA designation can be withdrawn, however, 

interested parties and groups must be allowed to provide data and 

information in support of the designation. A health center or rural health 

clinic receiving automatic facility HPSA designation must demonstrate 

every 6 years after receiving its automatic designation that it meets the 

definition of a HPSA.25

More than 5,500 HPSAs were located throughout the country as of 

September 2005. We estimated that over half of these HPSAs were 

geographic or population-group HPSAs; the rest were facility HPSAs. 

Numerous federal programs have used these HPSA designations to 

allocate their programs’ resources or provide benefits, which is an 

incentive for obtaining and retaining the HPSA designation. 

Using HRSA data, we identified 5,594 designated HPSAs as of September 

2005. We estimated that slightly more than half (3,032) of these HPSAs 

were designated for geographic areas or population groups. HRSA 

calculated that geographic and population-group HPSAs needed 6,941 

additional full-time primary care physicians to achieve ratios of population 

to primary care physicians that would remove the HPSA designations (see 

table 1). 

HPSAs Are Located in 

Every State and Are 

Used by Multiple 

Federal Programs 

Number and Location of 

HPSAs 

 2442 C.F.R. § 5.4(d) (2005). 

2542 U.S.C. § 254e(a)(1). 

Page 14 GAO-07-84 Health Professional Shortage Areas
Table 1: Number of, Population in, and Physicians Needed in Geographic and 

Population-Group HPSAs, September 2005

HPSA type Number of HPSAs Population in HPSAsa

Primary care 

physicians neededb

Geographic area 1,646 34,821,125 3,549

Population group 1,386 24,912,956 3,392

Total 3,032 59,734,081 6,941

Source: HRSA. 

a

These numbers represent the resident civilian population of the related HPSA. For example, for 

geographic HPSAs that consist of an entire county, this number reflects the resident civilian 

population of the entire county. For population-group HPSAs, this number reflects that groups’

population within particular geographic areas. 

b

The number of additional full-time-equivalent primary care physicians required to achieve populationto-primary care physician ratios of 3,500:1 (less than 3,500:1 but greater than 3,000:1 under special 

circumstances), which are needed to remove the HPSA designations. 

Of the 1,646 geographic HPSAs, slightly more than half (831) consisted of 

an entire county, and the remainder (815) consisted of other service areas

within counties, such as specific census tracts. As illustrated in figure 3,

geographic and population-group HPSAs designated as of January 2006 

were located in 2,494 counties in all 50 states and the District of 

Columbia.26

 26Geographic HPSAs were also located in American Samoa, the Commonwealth of the

Northern Mariana Islands, the Federated States of Micronesia, Guam, Puerto Rico, the

Republic of the Marshall Islands, and the Republic of Palau. Population-group HPSAs were

also located in Puerto Rico and the U.S. Virgin Islands. 

Page 15 GAO-07-84 Health Professional Shortage Areas
Figure 3: U.S. Counties with Geographic and Population-Group HPSAs, 

January 2006

Page 16 GAO-07-84 Health Professional Shortage Areas
 

 

Sources: GAO analysis of HRSA and U.S. Census Bureau data and MapInfo (map).

Did not have a geographic or population-group HPSA

Had a population-group HPSA

Had a partial-county geographic HPSA

Was a whole-county geographic HPSA

Note: Counties that contained both geographic and population-group HPSAs are shown as 

geographic HPSAs. We identified 218 counties that included both geographic and population-group 

HPSAs as of January 2006. 

Page 17 GAO-07-84 Health Professional Shortage Areas
We estimated that slightly less than half (2,562) of all HPSAs designated as 

of September 2005 were facility HPSAs. Of these, about 63 percent (1,625) 

were health centers,27 about 23 percent (590) were rural health clinics, and 

about 14 percent (347) were federal or state correctional institutions (see 

fig. 4). Excluded from this count of facility HPSAs were 136 public or 

nonprofit medical facilities that HRSA’s data indicated had requested and 

received a facility HPSA designation, but that HRSA officials said could be

duplicates of health centers that HRSA’s data showed as having 

automatically received a facility HPSA designation. Also excluded were 21 

health centers that HRSA’s data identified as health centers for Alaska 

Natives that received automatic facility HPSA designations, but that HRSA 

and IHS officials said could be duplicates of health centers HRSA’s data 

identified as tribal health centers. 

 27Of the 1,625 health centers that were automatically designated as facility HPSAs as of 

September 2005, we estimated 989 were grantees under HHS’s consolidated health center

program. (Consolidated health center program grantees may provide services at more than

one delivery site, and although data were not available on the number of these delivery 

sites, a HRSA official estimated that consolidated health center program grantees operated 

more than 3,700 service delivery sites in 2005.) In addition, we estimated 99 health center

look-alikes and 537 tribal health centers were automatically designated as facility HPSAs as 

of September 2005. 

Page 18 GAO-07-84 Health Professional Shortage Areas
Figure 4: Types of Facility HPSAs, September 2005 

Rural health clinics

Health centers

Federal or state

correctional institutions

Source: GAO analysis of HRSA data.

Health center look-alikes

Tribal health centers

Consolidated health centers

14%

23%

63%

21% 4% 

39% 

Health center HPSAs, which 

made up about 63% of 

facility HPSAs, are divided 

into three subtypes:

Note: Percentages of health center subtypes do not add to 63 percent because of rounding. 

As of September 2005, health centers with facility HPSA designations were 

located in all 50 states and the District of Columbia.28 Rural health clinics 

with facility HPSA designations were located in 41 states, and federal or 

state correctional institutions with facility HPSA designations were 

located in 46 states.29

 28Health centers with facility HPSA designations were also located in American Samoa, 

Guam, Puerto Rico, the Republic of the Marshall Islands, the Republic of Palau, and the 

U.S. Virgin Islands. 

29As of September 2005, rural health clinics with facility HPSA designations were located in

all states except the following: Alaska, Arizona, Connecticut, Delaware, Hawaii, 

Massachusetts, Maryland, New Jersey, and Rhode Island, as well as the District of 

Columbia. Federal or state correctional institutions with facility HPSA designations were 

located in all states except Alaska, Delaware, North Dakota, and New Mexico, as well as 

the District of Columbia. A federal or state correctional institution with a facility HPSA 

designation was also located in Puerto Rico. 

Page 19 GAO-07-84 Health Professional Shortage Areas
Although the HPSA designation system was originally used to designate 

areas for placement of providers through NHSC programs, the HPSA 

designation, and in some cases the HPSA score, have since been used by 

more than 30 federal programs to allocate resources or provide benefits. In 

fiscal year 2005, NHSC—which received $131 million in funding from 

HRSA appropriations—administered four programs that used the HPSA 

designation—three of which also used the HPSA score:30

Federal Programs Using 

HPSA Designations 

• NHSC Scholarship Program: NHSC awards scholarships to health 

professions students who agree to practice for at least 2 years in a HPSA 

after completing training as a primary care physician, nurse practitioner, 

nurse-midwife, physician assistant, or other eligible provider.31 Scholarship 

recipients are limited to practicing at NHSC-approved practice sites in 

HPSAs with high need, as determined by the HPSA designation score.32 For 

the period July 1, 2005, through June 30, 2006, scholarship recipients 

completing training who were primary care physicians were required to 

practice in HPSAs with scores of 14 or higher, while those completing 

training as nurse practitioners, physician assistants, and nurse-midwives 

were required to practice in HPSAs with scores of at least 13, 13, and 8, 

respectively.

33 At the end of fiscal year 2005, about 670 NHSC scholarship 

recipients, including primary care physicians, nurse practitioners, nurse-

 30A fifth NHSC program—the Community Scholarship Program—did not award any new

scholarships in fiscal year 2005, and therefore we excluded this program from our analysis. 

3142 U.S.C. § 254l(f)(1)(B)(v). Scholarship recipients receive payment of tuition and other 

educational expenses, such as fees and books, as well as a stipend for up to 4 years of

education. For each year of support received, the recipient is required to serve 1 year in an

NHSC-approved practice site in a high-need HPSA, with a minimum service commitment of

2 years. 

32NHSC providers must practice in NHSC-approved practice sites that agree to use a sliding 

fee schedule or other method to reduce fees to ensure that no financial barriers to care

exist. 

3370 Fed. Reg. 51356–7 (Aug. 30, 2005). The minimum HPSA score for the practice sites 

eligible for NHSC scholarship recipients in a given year depends on both the practice sites

applying for scholarship recipients in that discipline and the number of scholarship 

recipients graduating in each discipline that year. 

Page 20 GAO-07-84 Health Professional Shortage Areas
midwives, and physician assistants, were practicing in HPSAs to complete 

their NHSC service obligations.34

• NHSC Loan Repayment Program: NHSC repays educational loans of fully 

trained health professionals who agree to practice for at least 2 years in a 

HPSA.35 In addition to the practice sites approved for scholarship 

recipients, loan repayment recipients—including primary care physicians,

nurse practitioners, physician assistants, nurse-midwives, and other 

providers—may practice at NHSC-approved sites in other HPSAs, 

including those with lower HPSA scores. Loan repayment awards are 

made to providers who practice in higher-scoring HPSAs first, and then to 

providers who practice in lower-scoring HPSAs in descending order as 

long as program funds are available. Sufficient funds were available for 

fiscal years 2003 through 2005 to make awards to all providers with 

eligible and complete loan repayment applications, regardless of the 

practice location’s HPSA score. At the end of fiscal year 2005, about 1,700 

NHSC loan repayment recipients were practicing in HPSAs to complete 

their NHSC service obligations. 

• NHSC State Loan Repayment Program: NHSC provides grants to states to 

operate state loan repayment programs.36 Eligibility requirements and 

benefits, such as the maximum amount of loan repayment each year, may 

vary from state to state, but state loan repayment recipients must agree to 

provide primary health services in a HPSA. At the end of fiscal year 2005,

about 680 NHSC state loan repayment recipients were practicing in HPSAs 

under this program. 

 34In this report, the numbers of NHSC providers represent those primary care providers

practicing in HPSAs to fulfill their service obligation at the end of fiscal year 2005; they do 

not include about 550 NHSC dental providers and about 920 NHSC mental health providers

practicing in HPSAs designated for dental or mental health. The numbers also exclude 13 

NHSC loan repayment recipients who were chiropractors or pharmacists practicing in 

HPSAs to fulfill their NHSC service obligation under a demonstration project authorized by 

the Public Health Service Act. See 42 U.S.C. § 254t. 

3542 U.S.C. § 254l-1(f), (g). For the 2-year minimum service commitment, NHSC will pay up 

to $50,000, based on the loan repayment recipient’s qualifying educational loans, with the 

potential to participate in the program for additional years, one year at a time, with NHSC

paying up to $35,000 per year. See HRSA, Bureau of Health Professions, National Health 

Service Corps, “Loan Repayment Program,” http://nhsc.bhpr.hrsa.gov/join_us/lrp.asp 

(downloaded May 13, 2006).

3642 U.S.C. § 254q-1. States must provide matching funds to be eligible for a grant. 

Page 21 GAO-07-84 Health Professional Shortage Areas
• NHSC Ready Responder Program: Providers—including primary care 

physicians, nurse practitioners, physician assistants, and nurses—can 

receive salaries, benefits, and moving expenses to serve as commissioned 

officers in the U.S. Public Health Service who are assigned by NHSC to 

practice for 3 years in the neediest HPSAs.37 In determining practice 

locations for Ready Responders, NHSC gives preference to NHSCapproved sites in HPSAs with high scores. HRSA’s 2004 notice to recruit 

providers to participate in this program stated that NHSC Ready 

Responders would be part of a mobile team of health professionals who, in 

addition to the services they provide to patients at their assigned sites, 

might be called upon to respond to regional or national emergencies. At 

the end of fiscal year 2005, 56 NHSC Ready Responders were practicing in

HPSAs. 

In addition to the 4 NHSC programs, more than 26 other federal programs 

have used the HPSA designation to allocate resources or provide 

benefits.38 For example: 

• CMS’s Medicare Incentive Payment program pays physicians a 10 percent

bonus for services provided to Medicare beneficiaries in a geographic 

HPSA.39 According to CMS’s Office of Financial Management, the Medicare 

program paid about $148 million in these bonus payments in fiscal year 

2005. 

• CMS’s Rural Health Clinic program employs special payment rules for the 

reimbursement of services provided by rural health clinics under Medicare 

and Medicaid, which is an incentive for becoming a rural health clinic. For 

example, rural health clinics are reimbursed under a modified cost-based

method of payment under Medicare. For reimbursement purposes, a rural 

health clinic must be located in a geographic or population-group HPSA in 

a rural area, a rural area designated by a state’s governor (or chief 

executive officer) and certified by HHS as an area with a shortage of 

 3769 Fed. Reg.70459 (Dec. 6, 2004). Applicants for the Ready Responders must file a U.S.

Public Health Service Commissioned Corps application and meet the requirements for such

commissioning. Initial assignments will last up to 3 years, after which providers choosing 

to stay in the U.S. Public Health Service move on to new assignments. 

38See appendix IV for a list of programs using the HPSA designation and HRSA’s other 

designations of underservice (MUA and MUP) to allocate resources or provide benefits in 

fiscal year 2005. 

3942 U.S.C. § 1395l(m). 

Page 22 GAO-07-84 Health Professional Shortage Areas
personal health services, or a rural area HRSA has designated as a 

medically underserved area (MUA).40

• Federal agencies—including HHS, the Appalachian Regional 

Commission,

41 and the Delta Regional Authority42—as well as state health 

departments, operate programs, called J-1 visa waiver programs, to attract 

foreign physicians who have just completed their graduate medical 

education in the United States to practice in underserved areas. In 

exchange for a commitment to practice for at least 3 years at a facility 

located in, or treating residents of, a HPSA, an MUA, or a medically 

underserved population (MUP), foreign physicians can receive the benefit

of a waiver of a 2-year foreign residence requirement.43 Of the federal 

agencies administering J-1 visa waiver programs in 2005, HHS required 

foreign physicians receiving J-1 visa waivers through its J-1 visa waiver 

 40See appendix II for additional information on the MUA designation. 

41The Appalachian Regional Commission is a federal-state economic development 

partnership between the federal government and 13 states. The commission initiates 

economic and community development programs and serves as an advocate for the people 

in the Appalachian Region, including all of West Virginia and parts of 12 other states: 

Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio,

Pennsylvania, South Carolina, Tennessee, and Virginia. 

42The Delta Regional Authority is a federal-state partnership between the federal 

government and eight states. The authority was created to remedy severe and chronic 

economic distress by stimulating economic development and fostering partnerships that

will have a positive impact on the economy of the region. The authority covers 240 counties 

and parishes in Alabama, Arkansas, Illinois, Kentucky, Louisiana, Mississippi, Missouri, and

Tennessee.

43Foreign physicians may enter the United States for graduate medical education as 

participants under an exchange visitor program administered by the Department of State. 

These physicians enter the United States with J-1 visas and are required to return to their 

home country or country of last legal residence for at least 2 years when they complete 

their graduate medical education. They may, however, obtain a waiver of this requirement 

from the Department of Homeland Security’s U.S. Citizenship and Immigration Services

(USCIS) at the request of a state or federal agency, if the physician has agreed to practice

in or work at a facility that treats residents of a geographic area or areas designated by the

Secretary of Heath and Human Services as having a shortage of health care professionals, 

such as a HPSA, for 3 years. 8 U.S.C. § 1184(l)(1)(D). In May 2006, we testified that, in fiscal 

year 2005, states and federal agencies requested more than 1,000 waivers for physicians—

including those practicing primary care specialties and those practicing nonprimary care 

specialties—to work in facilities that are located in, or treat residents of, HPSAs or other 

underserved areas. More than 90 percent of these were states’ waiver requests; less than 

10 percent were federal agencies’ requests. See GAO, Foreign Physicians: Preliminary

Findings on the Use of J-1 Visa Waivers to Practice in Underserved Areas, GAO-06-773T 

(Washington, D.C.: May 18, 2006). 

Page 23 GAO-07-84 Health Professional Shortage Areas
program to practice in certain health centers, rural health clinics, or other 

facilities in HPSAs with a HPSA score of 14 or higher.44

• More than 15 federal programs that funded health professions education 

and training grants in fiscal year 2005 used the HPSA designation to 

provide funding preferences to grant applicants.45 Authorized under title 

VII of the Public Health Service Act—with more than $160 million in 

funding from HRSA’s fiscal year 2005 appropriations—these programs 

provided funding preferences to grant applicants, such as health 

professions schools that placed a high or increasing number of graduates 

in settings serving medically underserved communities, including HPSAs. 

For purposes of the funding preference, the Public Health Service Act 

defines medically underserved communities to include areas or 

populations that are eligible for HPSA designation, or that meet other 

criteria, such as being eligible to be served by a community or migrant 

health center.46

The use of the HPSA designation by more than 30 federal programs to 

allocate resources or provide benefits is an incentive for obtaining and 

retaining a HPSA designation, even if the HPSA does not want or need 

additional primary care providers. Agencies or individuals requesting 

initial designations or continuations of the HPSA designations for 

geographic areas, population groups, or facilities may instead want the 

designation for other purposes, for example, to be eligible for benefits 

such as the 10 percent bonus payment for physician services under CMS’s 

Medicare Incentive Payment program. In 1998, COGME reported that one 

possible reason that the number of HPSAs had not declined was that “as 

the penalty for designation loss has increased, organizations have become 

 44Effective April 3, 2006, HHS revised its J-1 visa waiver policy. Rather than require foreign 

physicians to practice in HPSAs with a score of 14 or higher, the revised policy requires

foreign physicians seeking a waiver to practice in HPSAs with a score of 7 or higher in 

order for HHS to request a J-1 visa waiver through its program. See HHS, “Applications for

Waiver of the Two-year Foreign Residence Requirement (Clinical Care) of the Exchange

Visitor Program,” http://www.globalhealth.gov/newguidelines1.shtml (downloaded Mar. 17, 

2006). 

45See 42 U.S.C. §§ 295d(c), 295j. Funding preferences are factors that place a grant 

application ahead of others without a preference on a list of applicants recommended for

funding by a review committee. 

4642 U.S.C. § 295p(6)(A), (B). 

Page 24 GAO-07-84 Health Professional Shortage Areas
more adept at making the case for retaining or attaining this coveted

status.”47

Of the reports published since 1995 that addressed the criteria or 

methodology used to designate HPSAs, we identified one that supported 

one key element of the criteria and six that pointed to shortcomings in the 

designation methodology. These six reports were consistent with what we 

reported in 1995. HHS officials have acknowledged these shortcomings 

and the department has been working on a proposal for revising the HPSA

designation system since 1998, which, as of September 2006, had not been

finalized. Another problem we identified in 1995 that persists in 2006 is 

HRSA’s lack of timely removal of HPSA designations that no longer meet 

the designation criteria.

Of the seven reports we identified as research on the HPSA criteria or 

methodology, one of the peer-reviewed reports addressed the relationship 

between one key element of the HPSA designation criteria and primary 

care physician supply. This report found a positive association between 

primary care physician supply and an area’s income—one of the elements

of the HPSA criteria used to demonstrate unusually high needs for primary 

care services. Specifically, the researchers found that areas with higher 

incomes had a greater number of primary care physicians than areas with 

lower incomes.48

Other published reports have, however, pointed to shortcomings in the 

methodology HRSA uses to designate HPSAs—specifically that the system 

has not effectively identified areas with primary care shortages or helped

Research Points to 

Shortcomings with 

Designation 

Methodology 

 47Council on Graduate Medical Education, Department of Health and Human Services, 

Health Resources and Services Administration, Tenth Report: Physician Distribution and

Health Care Challenges in Rural and Inner-City Areas (Rockville, Md.: February 1998). 

48Kevin Grumbach et al., “Physician Supply and Access to Care in Urban Communities,” 

Health Affairs, vol. 16, no. 1 (1997). For this report, researchers analyzed data from a 1993

survey of a sample of California residents from 41 urban communities based on guidelines 

for defining primary care service areas developed by state agencies. Researchers examined

the relationship between income of the respondents and the number of physicians per 

100,000 population in those areas, using data from the 1994 American Medical Association 

Physician Masterfile for physicians in medical specialties of general or family practice, 

general internal medicine, pediatrics, and obstetrics and gynecology. 

Page 25 GAO-07-84 Health Professional Shortage Areas
target federal resources to benefit those who are underserved.49 For 

example, reports—including one we issued in 1995—have noted that 

HRSA’s designation methodology does not accurately identify those 

providers available to furnish primary health care services.50 As a result, 

the HPSA methodology can overstate the need for additional primary care 

providers, limiting the usefulness of the HPSA designation system as a 

screen to identify which communities should be eligible for additional 

program benefits. Since 1995, we and others have reported problems with 

HRSA’s exclusion of several categories of primary care providers when 

calculating the available primary care providers. For example, in our 1995

report, we estimated that the reported need for additional providers in 

1994 would have been reduced by up to 50 percent if certain categories of

primary care physicians and nonphysician providers—which were 

excluded by HRSA—had been included in the HPSA calculations.51 In total, 

we estimated that 2,539 primary care physicians already providing services 

in shortage areas (including NHSC physicians and foreign physicians with 

J-1 visa waivers) and other categories of providers who deliver primary 

care services in HPSAs (including physician assistants and nursemidwives) were excluded by HRSA in 1994. 

Reports have also concluded that some of the geographic areas that HRSA 

evaluates for designation—that is, those based on county boundaries—

may not always provide a realistic reflection of an area’s health care 

needs. For these HPSA designation requests, measuring the availability of 

primary care physicians only in the county where individuals live may 

underestimate certain residents’ access to medical care.52 For example, 

two reports we identified discussed the likelihood of people crossing 

 49See, for example, Council on Graduate Medical Education, Department of Health and

Human Services, Health Resources and Services Administration, Tenth Report: Physician

Distribution and Health Care Challenges in Rural and Inner-City Areas, and Donald H.

Taylor Jr. and Thomas C. Ricketts, “Examining Alternative Measures of Medical 

Underservice for Rural Areas: Executive Summary” (Working Paper No. 39, North Carolina 

Rural Health Research Program, Cecil G. Sheps Center for Health Services Research, 

University of North Carolina at Chapel Hill, August 1995).

50See GAO/HEHS-95-200. 

51This estimate was derived by subtracting the total number of primary care providers 

practicing in HPSAs from the total number reported as needed by the HPSA system. See 

GAO/HEHS-95-200. 

52Not all HPSAs rely on county-level data. For example, in September 2005, although 831

geographic HPSAs were entire counties, 815 geographic HPSAs were portions of counties,

such as census tracts. 

Page 26 GAO-07-84 Health Professional Shortage Areas
county lines to obtain health care services when these services were not 

available in their community.53 In one report, researchers evaluated the 

relationship between health status and medical care resources and found 

that individuals aged 64 years or younger living in nonmetropolitan areas 

reported better health when there was greater physician supply in the 

county where they lived and adjoining counties. According to these 

researchers, the results suggested that younger individuals in 

nonmetropolitan areas were willing and able to cross county lines to 

obtain health care.54

Researchers have also noted that the HPSA designation methodology 

favors those states or areas that have experience in completing and 

submitting a HPSA designation request.55 One team of researchers reported 

that officials in certain states and localities were effective in identifying 

areas that would qualify for a HPSA designation and in providing timely 

and appropriate data for the request, whereas other areas were unable to 

navigate the process as effectively. The researchers observed that certain

areas were more likely to have HPSA designations than others—

independent of the actual local situation.56

Recognizing the shortcomings in the HPSA designation system identified 

by available research and our prior work, HHS has been working on a 

proposal for a revised designation system since 1998. According to HRSA 

officials, the proposal incorporates factors to account for all primary care 

providers in an area—including foreign physicians with J-1 visa waivers, 

NHSC physicians, and nurse practitioners and physician assistants—and 

includes the creation of a master database to house national data relevant 

 53See John Robst and Glenn G. Graham, “The Relationship between the Supply of Primary

Care Physicians and Measures of Heath,” Eastern Economic Journal, vol. 30, no. 3 (2004),

and Richard A. Wright et al., “Finding the Medically Underserved: A Need to Revise the 

Federal Definition,” Journal of Health Care for the Poor and Underserved, vol. 7, no. 4 

(1996). 

54Robst and Graham, “The Relationship between the Supply of Primary Care Physicians and 

Measures of Heath.” 

55See, for example, Council on Graduate Medical Education, Department of Health and

Human Services, Health Resources and Services Administration, Tenth Report: Physician

Distribution and Health Care Challenges in Rural and Inner-City Areas, and Taylor and 

Ricketts, “Examining Alternative Measures of Medical Underservice for Rural Areas: 

Executive Summary.” 

56Taylor and Ricketts, “Examining Alternative Measures of Medical Underservice for Rural 

Areas: Executive Summary.” 

Page 27 GAO-07-84 Health Professional Shortage Areas
to HPSA criteria. As of September 2006, this proposal was in the 

department’s clearance process. 

Another problem we identified in 1995, that remains a problem in 2006, is

that HRSA does not review designated HPSAs and subsequently remove 

the designation of those areas, population groups, or facilities that no 

longer meet the HPSA criteria in a timely manner. While we did not audit

HRSA’s process for periodically reviewing HPSAs, in August 2005, the HHS 

Office of Inspector General reported that as of 2003, HRSA had not 

conducted timely reviews of HPSA designations.57 In the agency’s 

comments that were included in the August 2005 report, HRSA 

acknowledged this problem, stating that the agency was unable to 

complete the review of designated HPSAs for continued eligibility in less 

than 3 years because of resource limitations. As of September 2006, we 

found that although HHS is required to publish a list of designated HPSAs 

in the Federal Register by July 1 of each year—thereby removing the 

designation of any HPSAs that were proposed for withdrawal that are not 

published—the department has not done so since February 2002.58 HRSA 

officials told us in June 2006 that the department has not published a list of

HPSAs in the Federal Register for more than 4 years because of difficulties 

with computer programming, but the agency hoped to resolve those issues 

and to forward an updated list for publication by fall 2006.59 Meanwhile, 

those HPSAs that were proposed for withdrawal because they no longer

 57Office of Inspector General, Department of Health and Human Services, Status of the 

Rural Health Clinic Program, OEI-05-03-00170 (Chicago: August 2005). The Inspector 

General’s review was limited to those HPSAs where rural health clinics were located. 

HRSA stated in its response to this report that the actual submission of updates of HPSA

data by interested parties and groups, and the review and action for existing HPSA 

designations by HRSA, took place after the fourth or possibly fifth year after a HPSA 

designation was received. HRSA also stated that its ability to review depended on the 

number of requests HRSA received for individual HPSA updates and the complexity of 

those requests. 

5867 Fed. Reg. 7740–88 (Feb. 20, 2002). 

59According to HRSA officials, the impact of not publishing a list of designated HPSAs in

the Federal Register may have been lessened because (1) HRSA has a publicly available 

Web-based application that can be used to search a regularly updated, real-time database of 

HPSA designations, including those proposed for withdrawal, and (2) NHSC, for which the

HPSA designations were originally developed and the major reason for the designations, 

does not place providers in HPSAs that are proposed for withdrawal, so the absence of the

Federal Register publication has not affected the practice locations for NHSC programs. 

HHS officials also noted that, for other programs that use the HPSA designation, the 

decision to use or not use HPSAs proposed for withdrawal is generally made by the 

individual programs. 

Page 28 GAO-07-84 Health Professional Shortage Areas
meet the HPSA criteria have retained their HPSA designation.60 As a result, 

federal programs that use the HPSA designation, such as the Medicare 

Incentive Payment program or HRSA’s health professions education and

training programs, may have been allocating resources or providing 

benefits to areas, population groups, or facilities that no longer meet the 

HPSA criteria. 

Many health centers and rural health clinics did not benefit from 

automatic designation as facility HPSAs because they were located in

geographic or population-group HPSAs. Most health centers also received

a HPSA score associated with the automatic designation that was too low 

to qualify them for programs that required a minimum HPSA score in 2005, 

although they qualified for programs that did not have such a requirement. 

Of the relatively few rural health clinics that chose to certify that they

would treat anyone regardless of ability to pay and, as a result, received 

the automatic designation as facility HPSAs, most also received scores too 

low to qualify for benefits from certain programs that required a higher 

HPSA score. 

For health centers that were located in a geographic or population-group 

HPSA, automatic designation as a facility HPSA provided no benefit unless 

the HPSA score associated with automatic designation was higher than the 

score for the geographic or population-group HPSA in which they were 

located. According to the National Association of Community Health 

Centers, health centers had advocated for automatic HPSA designation 

because it would allow those not located in geographic or populationgroup HPSAs to be eligible for providers from NHSC. Although limitations 

in HRSA’s data prevented us from measuring the precise impact of the

automatic HPSA designation on health centers, HRSA officials estimated 

that about half of the health centers that received automatic designation as 

a facility HPSA in 2002 were located in a geographic or population-group 

HPSA and therefore did not receive this benefit. 

As of September 2005, 73 (less than 5 percent) of the 1,625 health centers 

that had received automatic designation as facility HPSAs had an 

Many Health Centers 

and Rural Health 

Clinics Did Not 

Benefit from 

Automatic HPSA 

Designation 

Relatively Few Health 

Centers Had HPSA Scores 

High Enough to Obtain 

Providers through Certain 

Federal Programs 

 60Of the 2,746 geographic and population-group HPSAs designated as of January 2006,

about 12 percent were proposed for withdrawal because they no longer met the criteria or

had not provided HRSA with updated data in support of their designations.

Page 29 GAO-07-84 Health Professional Shortage Areas
associated HPSA score high enough to qualify for a physician through the 

NHSC Scholarship Program or HHS’s J-1 visa waiver program.61 These 

health centers received a HPSA score of 14 or higher—the HPSA score 

required by these programs for physician placement (see fig. 5). Eighty-six

(about 5 percent) of the 1,625 health centers with automatic facility HPSA

designation received a HPSA score of 13 or higher—the HPSA score 

required by the NHSC Scholarship Program to qualify for placement of a 

nurse practitioner or physician assistant. 

 61One tribal health center had not received a HPSA score from HRSA as of September 2005. 

Although health centers receiving automatic designation could also use the score of a

geographic or population-group HPSA if the facility was located in one, HRSA officials we 

spoke with did not have data on how many health centers that were eligible for this

provision chose to use it when applying for federal programs. 

Page 30 GAO-07-84 Health Professional Shortage Areas
Figure 5: Distribution of HPSA Scores among Health Centers Automatically Designated as Facility HPSAs, September 2005 

Number of health centers

Scoreb

Source: GAO analysis of HRSA data.

0

25

50

75

100

125

150

175

200

225

250

275

300

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

In September 2005, physicians participating in the 

NHSC Scholarship Program or HHS's J-1 visa waiver 

program were required to practice in HPSAs with 

scores of 14 or higher.a

185

141

124

151

132

283

156 152

75 68

41

14 16 13 15

4 8 11 15 12 6 2 0000

Notes: This figure includes scores for 1,624 of the 1,625 health centers that, as of September 2005, 

received a HPSA score as part of automatic designation as a facility HPSA. One tribal health center

had not received a HPSA score from HRSA as of September 2005. Health centers that automatically 

received facility HPSA designation include those that received grants under the consolidated health

center program, health center look-alikes, and tribal health centers.

a

For assignment of NHSC providers through the NHSC Scholarship Program for the period July 1, 

2005, through June 30, 2006, a HPSA score of 14 or higher was required to be eligible for a 

physician; a score of 13 or higher was required for a nurse practitioner or physician assistant; and a 

score of 8 or higher was required for a nurse-midwife. HHS’s J-1 visa waiver program required a 

HPSA score of 14 or higher for all of 2005. 

b

The maximum HPSA score a health center can receive is 25. 

In contrast, automatic facility HPSA designation made health centers 

eligible, regardless of HPSA score, to apply in 2005 for a physician or other 

health care provider through the NHSC Loan Repayment Program.62

According to an official with the National Association of Community 

Health Centers, health center officials were pleased with this benefit but 

also viewed it with caution because NHSC loan repayment awards are 

 62In addition to the NHSC Loan Repayment Program, health centers with automatic facility 

HPSA designations were eligible to apply for other programs that did not require a HPSA 

score, such as J-1 visa waiver programs administered by the Appalachian Regional 

Commission, the Delta Regional Authority, and many state health departments. 

Page 31 GAO-07-84 Health Professional Shortage Areas
made first to providers who agree to practice in higher-scoring HPSAs and 

then to providers who agree to practice in lower-scoring HPSAs, in 

decreasing order of HPSA score. Although NHSC had sufficient funding for 

all qualifying loan repayment applicants from 2003 through 2005, health 

center officials were concerned that in future years, NHSC funding may be

insufficient to sustain this benefit for health centers with relatively low 

HPSA scores. 

Few Rural Health Clinics 

Have Received Automatic 

HPSA Designation as 

Facility HPSAs 

As of September 2005, 590 (16 percent) of the 3,637 rural health clinics in 

the United States had received automatic designation as facility HPSAs. To 

receive automatic designation, rural health clinics, unlike health centers, 

must certify that they provide health care services regardless of an 

individual’s ability to pay. To qualify for automatic HPSA designation, 

some rural health clinics—including those that are for-profit entities—

would have to restructure their billing practices, and according to officials 

at the National Association of Rural Health Clinics and HRSA’s Office of 

Rural Health Policy, it may not be in their interest to do so. 

As with health centers, the main benefit cited by officials at the Office of 

Rural Health Policy of automatic HPSA designation for rural health clinics 

is to be eligible for NHSC physicians or other primary care providers. 

Rural health clinics that were located in geographic or population-group 

HPSAs would not benefit from automatic designation unless the 

associated HPSA score was higher than the score for the geographic or 

population-group HPSAs in which they were located. Data were not 

available to determine how many of the 590 rural health clinics with 

automatic facility HPSA designations were located in geographic or 

population-group HPSAs before the 2002 provision was implemented. An 

official at the National Association of Rural Health Clinics reported, 

however, that a recent study estimated that over 70 percent of all rural 

health clinics—including those that did not receive the automatic facility 

HPSA designation—were located in geographic HPSAs before 2002 and 

Page 32 GAO-07-84 Health Professional Shortage Areas
were therefore already eligible for federal programs requiring HPSA 

designation.63

As of September 2005, less than 1 percent of the 590 rural health clinics 

that had received automatic designation as facility HPSAs had associated 

HPSA scores of 14 or higher needed to qualify for a physician through the

NHSC Scholarship Program or HHS’s J-1 visa waiver program (see fig. 6).64

About 1 percent received a HPSA score of 13 or higher—the HPSA score 

required by the NHSC Scholarship Program to qualify for a nurse 

practitioner or physician assistant. Like health centers with lower HPSA 

scores, rural health clinics automatically designated as facility HPSAs but 

scoring lower than 14 could recruit a physician or other provider through 

the NHSC Loan Repayment Program.65

 63See John A. Gale and Andrew F. Coburn, The Characteristics and Roles of Rural Health

Clinics in the United States: A Chartbook, (Portland, Me.: Maine Rural Health Research 

Center, Institute for Health Policy, Edmund S. Muskie School of Public Service, University 

of Southern Maine, 2003). In addition, our analysis of data prepared for HRSA’s Office of 

Rural Health Policy using 2003 and 2004 CMS data on rural health clinics and 2005 HRSA 

data on HPSAs indicated that nearly half of all rural health clinics—including those that did

not receive automatic designation—were located in geographic or population-group

HPSAs. 

64As of September 2005, 7 of the 590 rural health clinics that received automatic HPSA 

designation had not received a HPSA score from HRSA. Although rural health clinics

receiving automatic designation could also use the score of a geographic or populationgroup HPSA if the facility was located in one, HRSA officials we spoke with did not have 

data on how many rural health clinics that were eligible for this provision chose to use it 

when applying for federal programs. 

65In addition to the NHSC Loan Repayment Program, rural health clinics with automatic 

facility HPSA designations were eligible to apply for other programs that did not require a

HPSA score, such as J-1 visa waiver programs administered by the Appalachian Regional

Commission, the Delta Regional Authority, and many state health departments. 

Page 33 GAO-07-84 Health Professional Shortage Areas
Figure 6: Distribution of HPSA Scores among Rural Health Clinics Automatically Designated as Facility HPSAs, September 

2005 

Number of rural health clinics

Scoreb

Source: GAO analysis of HRSA data.

0

25

50

75

100

125

150

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

30

111

136

112

45

37

45

23

13

7 5 3

9

3 3 0 1 0 0 0 0 00 0 0 0

In September 2005, physicians participating in the 

NHSC Scholarship Program or HHS's J-1 visa waiver 

program were required to practice in HPSAs with 

scores of 14 or higher.a

Notes: This figure includes scores for 583 of the 590 rural health clinics that, as of September 2005, 

received a HPSA score as part of automatic designation as a facility HPSA. Seven rural health clinics

that received the automatic HPSA designation had not received a HPSA score from HRSA as of

September 2005.

a

For assignment of NHSC providers through the NHSC Scholarship Program for the period July 1, 

2005, through June 30, 2006, a HPSA score of 14 or higher was required to be eligible for a 

physician; a score of 13 or higher was required for a nurse practitioner or physician assistant; and a 

score of 8 or higher was required for a nurse-midwife. HHS’s J-1 visa waiver program required a 

HPSA score of 14 or higher for all of 2005. 

b

The maximum HPSA score a rural health clinic can receive is 25. 

Many federal programs continue to rely on HPSA designations to allocate

federal resources or provide benefits, even though shortcomings we and 

others have reported since 1995 have not been addressed. In particular, 

the omission of important categories of primary care providers—such as 

foreign physicians with J-1 visa waivers and nonphysician primary care 

providers—from calculations for HPSA designation can overstate the need

for additional primary care providers. Although HHS has recognized the 

need for improvements and has been working since 1998 on a proposal to 

revise the HPSA designation system, it remains to be seen when HHS will 

make such improvements and what changes will be made. In addition, 

HRSA has not regularly removed the HPSA designation of those areas, 

Conclusions 

Page 34 GAO-07-84 Health Professional Shortage Areas
population groups, or facilities that no longer meet the designation 

criteria. 

Available information suggests that the provision to automatically 

designate health centers and certain rural health clinics as facility HPSAs 

has benefited a relatively small number of these facilities. The precise 

impact of the provision could not be measured, however, because of 

limitations with available HHS data. For example, the available data did 

not include sufficient geographic information to determine which of these 

facilities were located in geographic or population-group HPSAs before 

receiving automatic designation as facility HPSAs. 

We recommend that the Secretary of Health and Human Services take the

following two actions: (1) publish a list of designated HPSAs in the Federal 

Register or otherwise remove, through Federal Register notification, the 

HPSA designations for those HPSAs that no longer meet the criteria or 

have not provided updated data in support of their designations and 

(2) complete and publish HHS’s proposal to revise the HPSA designation 

system and address the shortcomings that have been identified in the 

current methodology for designating HPSAs. 

We received comments on a draft of this report from HHS (see app. V). 

The department generally agreed with our findings and concurred with 

both recommendations. Specifically, the department agreed that a more 

timely publication of the Federal Register listing of designated HPSAs is 

necessary to ensure that only those areas meeting the regulations remain 

designated, and stated that HRSA should publish lists of HPSAs or HPSA 

withdrawals to ensure that designations that have already been proposed

for withdrawal are actually withdrawn. The department also noted that it

is proposing a change in the process for withdrawing HPSA designations, 

but it did not provide any details on this proposal. HHS also agreed with 

our recommendation that the department complete and publish its 

proposal to revise the HPSA designation system. HHS stated that this 

proposal would address shortcomings that we identified in this and 

previous reports and would also affect the regulations governing MUA and 

MUP designations. 

Recommendations for 

Executive Action 

Agency Comments 

HHS also commented on our finding that many health centers and rural 

health clinics did not benefit from automatic designation as facility HPSAs. 

Specifically, HHS stated that our draft report provided a somewhat 

misleading assessment of the impact of the automatic designation process 

Page 35 GAO-07-84 Health Professional Shortage Areas
and the department provided additional information on NHSC placements 

in automatically designated HPSAs in 2005. Our draft report stated that 

few health centers had HPSA scores associated with automatic 

designation that were high enough to qualify for a physician through the 

NHSC Scholarship Program, but that all health centers that received

automatic designation as HPSAs, even those with lower HPSA scores, 

could apply in 2005 for a health care provider through the NHSC Loan 

Repayment Program. The data the department provided on NHSC 

placements in automatically designated health centers were actually 

consistent with the statement in our draft report. HHS’s data, which HHS 

officials said included both primary care and nonprimary care providers, 

showed that of 216 NHSC providers placed in health centers, relatively few 

(less than 5 percent) were placed through the NHSC Scholarship Program 

and the NHSC Ready Responder Program (less than 1 percent), whereas 

the vast majority (more than 95 percent) were placed through the NHSC 

Loan Repayment Program. According to HRSA officials, data for primary 

care provider placements (which were not included in the department’s 

comments), showed a similar distribution between the three NHSC 

programs for 155 primary care NHSC placements in health centers in 2005. 

In its comments, HHS also provided information on the process for scoring 

automatically designated HPSAs and on NHSC and J-1 visa waiver 

programs. In response, we added information on J-1 visa waiver programs 

administered by federal agencies other than HHS and by state health 

departments. 

Finally, HHS suggested that we clarify that our scope was limited to 

primary care HPSAs. We made revisions to the report to highlight that our 

review only examined primary care HPSA designations. 

The department also provided technical comments, which we 

incorporated as appropriate. 

We are sending copies of this report to the Secretary of Health and Human 

Services, the Administrator of HRSA, the Administrator of CMS, and to 

appropriate congressional committees. We will also provide copies to 

others upon request. In addition, the report will be available at no charge 

on the GAO Web site at http://www.gao.gov. 

Page 36 GAO-07-84 Health Professional Shortage Areas
If you or your staff members have any questions about this report, please 

contact me at (312) 220-7600 or aronovitzl@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on the 

last page of this report. GAO staff members who made contributions to 

this report are listed in appendix VI.

Leslie G. Aronovitz 

Director, Health Care 

Page 37 GAO-07-84 Health Professional Shortage Areas
Appendix I: Scoring of Health Professional

Appendix I: Scoring of Health Professional Shortage Areas

Shortage Areas 

Each designated health professional shortage area (HPSA) receives a 

score that the Department of Health and Human Services’s (HHS) Health 

Resources and Services Administration (HRSA) uses to rank its shortage 

of primary care providers, or need, relative to other HPSAs. The HPSA 

score is used by some federal programs, such as the National Health 

Service Corps (NHSC) Scholarship Program, which requires participants 

to practice in locations with higher HPSA scores. The scores, ranging from 

0 to 25, are based on four factors, for which each HPSA is given a certain 

number of points (see fig. 7). To calculate a HPSA score, points for the 

population–to–primary care physician ratio, ranging from 1 to 5 points, are 

doubled and then summed with the points for each of the other three 

factors. For health centers and rural health clinics receiving automatic 

designation as facility HPSAs, if complete data are not available, or if 

HRSA cannot match the facility to appropriate data to calculate a HPSA 

score, the HPSA receives either a score of 0 or a partial score based on the 

sum of factors for which data are obtainable. 

Page 38 GAO-07-84 Health Professional Shortage Areas
Appendix I: Scoring of Health Professional

Shortage Areas

Figure 7: Scoring of HPSAs, 2005 

Source: HRSA.

HPSA =

score

HPSA

score

HPSA

score

Factor 1: Population–to–primary care physician ratioa

Points Criteria

10 points If there is only 1 physician for every 10,000 or more people, or no physician for a population 

equal to or greater than 2,500 

8 points If there is only 1 physician for every 5,000–9,999 people, or no physician for a population equal to 

or greater than 2,000 but less than 2,500

6 points If there is only 1 physician for every 4,000–4,999 people, or no physician for a population equal to 

or greater than 1,500 but less than 2,000

4 points If there is only 1 physician for every 3,500–3,999 people, or no physician for a population equal to 

or greater than 1,000 but less than 1,500

2 points If there is only 1 physician for every 3,000–3,499 people, or no physician for a population equal to 

or greater than 500 but less than 1,000

Factor 3: Lower of infant mortality rate or rate of low birth weight babiesc

Points Criteria

5 points If the infant mortality rate is equal to or greater than 20, or the low birth weight rate is equal to or 

greater than 13

4 points If the infant mortality rate is equal to or greater than 18 but less than 20, or the low birth weight 

rate is equal to or greater than 11 but less than 13

3 points If the infant mortality rate is equal to or greater than 15 but less than 18, or the low birth weight 

rate is equal to or greater than 10 but less than 11

2 points If the infant mortality rate is equal to or greater than 12 but less than 15, or the low birth weight 

rate is equal to or greater than 9 but less than 10

1 point If the infant mortality rate is equal to or greater than 10 but less than 12, or the low birth weight 

rate is equal to or greater than 7 but less than 9

0 points If the infant mortality rate is less than 10, or the low birth weight rate is less than 7

Factor 2: Percentage of population with income below 100 percent of the federal

poverty levelb

Points Criteria

5 points If the percentage is equal to or greater than 50

4 points If the percentage is equal to or greater than 40 but less than 50

3 points If the percentage is equal to or greater than 30 but less than 40

2 points If the percentage is equal to or greater than 20 but less than 30

1 point If the percentage is equal to or greater than 15 but less than 20

0 points If the percentage is less than 15

Factor 4: Higher of travel time or distance to nearest available source of primary care

Points Criteria

5 points If the travel time is equal to 60 minutes or more, or the distance is equal to 50 miles or more

4 points If the travel time is equal to 50 to 59 minutes, or the distance is equal to 40 to 49 miles

3 points If the travel time is equal to 40 to 49 minutes, or the distance is equal to 30 to 39 miles

2 points If the travel time is equal to 30 to 39 minutes, or the distance is equal to 20 to 29 miles

1 point If the travel time is equal to 20 to 29 minutes, or the distance is equal to 10 to 19 miles

0 points If the travel time is less than 20 minutes, or the distance is less than 10 miles

Page 39 GAO-07-84 Health Professional Shortage Areas
Appendix I: Scoring of Health Professional

Shortage Areas

a

For HPSA designation and scoring, HRSA counts nonfederal physicians who practice principally in 

one of the primary care specialties of general or family practice, general internal medicine, pediatrics, 

or obstetrics and gynecology. HRSA does not count federal physicians; physicians with NHSC or J-1 

visa waiver obligations; or physicians engaged solely in administration, research, or teaching. See 

HRSA, Bureau of Health Professions, “Health Professional Shortage Area Guidelines for Primary 

Medical Care/Dental Designation,” http://bhpr.hrsa.gov/shortage/hpsaguidepc.htm (downloaded 

Nov. 14, 2005). 

b

HHS’s poverty guidelines for 2005 set the poverty level for a family of four at an annual income of 

$19,350 in the 48 contiguous states and the District of Columbia ($24,190 in Alaska and $22,260 in 

Hawaii). Poverty guidelines are not defined for American Samoa, the Commonwealth of the Northern 

Mariana Islands, the Federated States of Micronesia, Guam, Puerto Rico, the Republic of the 

Marshall Islands, the Republic of Palau, and the U.S. Virgin Islands; offices administering federal 

programs may decide whether to use the guidelines for the 48 contiguous states and the District of 

Columbia for those jurisdictions or some other procedure. 70 Fed. Reg. 8373–75 (Feb. 18, 2005). 

c

Infant mortality rate is defined as the number of infant deaths per 1,000 live births. Low birth weight 

rate is defined as the percentage of live births below 2,500 grams (5 pounds, 8 ounces). 

Page 40 GAO-07-84 Health Professional Shortage Areas
Appendix II: Medically Underserved Area or 

Population Designations and Medically Appendix II: Medically Underserved Area or Underserved Community Definition

Population Designations and Medically 

Underserved Community Definition 

Medically underserved areas (MUA) and medically underserved 

populations (MUP) generally are areas, or populations within areas, that

are designated by HHS’s HRSA as having a shortage of health care 

services. The MUA and MUP designations were developed about the same 

time as the HPSA designation system but independently from it. 

Authorized by the Health Maintenance Organization Act of 1973, MUA and 

MUP designations have been used for identifying areas eligible to 

participate in the consolidated health center program. That is, in order to 

receive health center grant funding as a community health center, migrant 

health center, or a center serving residents of public housing or the 

homeless, the health center must be located in or serve the residents of an 

MUA or MUP. 

MUAs are designated for the entire population of a particular geographic 

area. MUP designations are limited to particular groups of underserved 

people within an area. Individual facilities are not eligible for MUA or MUP 

designations as they are under the HPSA designation system. As of 

September 2005, HRSA had designated 3,443 geographic areas as MUAs 

and 488 population groups as MUPs. 

HRSA designates MUAs and MUPs on the basis of four factors of health 

service need, the first three of which are also used for HPSA designation 

or scoring: 

• ratio of population to number of primary care physicians, 

• infant mortality rate, 

• percentage of the population with incomes below the federal poverty level, 

and 

• percentage of population aged 65 or over. 

To determine if an area meets the criteria to be designated as an MUA or if 

a population within an area meets the criteria to be designated as an MUP, 

each factor is assigned a weighted value, and these values are summed to 

Page 41 GAO-07-84 Health Professional Shortage Areas
Appendix II: Medically Underserved Area or 

Population Designations and Medically 

Underserved Community Definition

obtain a combined score.1 This score is used to determine if an area or 

population can be designated as an MUA or MUP. Areas and populations 

in the country are ranked using this score to determine their order of need 

of health services. Areas and populations with scores at or below 62 (the 

median score that was calculated for all U.S. counties in 1975 for the four 

criteria) are designated MUAs or MUPs. Those populations within areas 

with scores above 62 may still be designated as MUPs if they demonstrate 

that unusual local conditions impede access to or the availability of 

personal health services. Such requests must be documented and 

recommended by the state chief executive officer and the responsible 

local officials. 

One of the ways in which MUAs and MUPs differ from HPSAs is that MUA 

and MUP designations are not required to be regularly updated. According 

to a HRSA official, some areas with MUA or MUP designations have not 

been reviewed since the 1980s. In 1998, HHS published a proposal in the 

Federal Register to revise the MUA and MUP designations and combine 

them with the HPSA designation system.2

 The department received over 

800 comments on the proposal; subsequently, HHS withdrew the proposal 

and began working on another one, which, as of September 2006, was in 

the department’s clearance process. 

Another term—medically underserved community—is used to identify 

underserved areas for purposes of funding preferences for health 

professions education and training programs authorized under title VII of

the Public Health Service Act.3

 A medically underserved community is 

defined as an urban or rural area or population that 

• is eligible for HPSA designation; 

 1

Criteria for designation of MUAs and MUPs are based on the index of medical 

underservice, published in the Federal Register on October 15, 1976, and on the provisions

of Pub. L. No. 99-280, enacted in 1986. Areas or populations are scored on a scale of 0 to

100, where 0 represents completely underserved and 100 represents best served or least 

underserved. Each service area or population group within an area found to have a score of

62 or less qualifies for designation as an MUA or MUP. See HRSA, Bureau of Health 

Professions, “Guidelines for Medically Underserved Area and Population Designation,” 

http://bhpr.hrsa.gov/shortage/muaguide.htm (downloaded on June 23, 2006). 

2

63 Fed. Reg. 46538–55 (Sept. 1, 1998). 

3

Funding preferences are factors that place a grant application ahead of others without a

preference on a list of applicants recommended for funding by a review committee. 

Page 42 GAO-07-84 Health Professional Shortage Areas
Appendix II: Medically Underserved Area or 

Population Designations and Medically 

Underserved Community Definition

• is eligible to be served by a community health center, migrant health 

center, or a grantee serving residents of public housing or the homeless; 

• has a shortage of personal health services, as determined under criteria 

issued by the Secretary of Health and Human Services under section 

1861(aa)(2) of the Social Security Act (relating to rural health clinics); or 

• is designated by a state governor (in consultation with the medical 

community) as a shortage area or medically underserved community.4

In fiscal year 2005, 15 programs authorized under title VII, with funding of 

more than $160 million, provided funding preferences for any qualified 

applicant, such as a health professions school, that had a high rate for 

placing graduates in practice settings having the principal focus of serving 

residents of medically underserved communities or that achieved a 

significant increase in the rate of placing graduates in such settings during 

the previous 2-year period.

5

In addition, two nursing traineeship programs authorized under title VIII of 

the Public Health Service Act used the medically underserved community 

definition in providing a funding preference to grant applicants. Title VIII 

provides a funding preference that includes nursing workforce grant 

applicants with projects that will substantially benefit rural or underserved 

populations.6

 For purposes of this statutory funding preference for two 

title VIII programs—the Advanced Education Nursing Traineeship 

Program and Nurse Anesthetist Traineeship Program—HHS used 

established clinical sites identified under the definition of medically 

underserved community as proxies for rural and underserved populations. 

 4

42 U.S.C. § 295p(6). In fiscal year 2005 guidance to grant applicants, HRSA stated that 

medically underserved communities include health centers (including those for migrant 

workers, the homeless, and residents of public housing); rural health clinics; National

Health Service Corps (NHSC) sites; Indian Health Service (IHS) sites; HPSAs; state or local 

health departments; and sites in a shortage area designated by a state governor. 

5

42 U.S.C. § 295j. An additional grant program authorized under title VII of the Public 

Health Service Act provides a funding preference for applicants that have not less than 

25 percent of their graduates in full-time practice settings in medically underserved 

communities, that recruit and admit students from medically underserved communities, 

that have established relationships with public and nonprofit providers of health care in the 

community involved, and that emphasize employment with public and nonprofit entities in 

their training of students. 42 U.S.C. § 295d(c).

6

42 U.S.C. § 296d. The preference also applies to applicants that will help meet public 

health nursing needs in state or local health departments. 

Page 43 GAO-07-84 Health Professional Shortage Areas
Appendix II: Medically Underserved Area or 

Population Designations and Medically 

Underserved Community Definition

In fiscal year 2005, these two programs authorized under title VIII had 

about $17 million in funding. 

Page 44 GAO-07-84 Health Professional Shortage Areas
Appendix III: Scope and Methodology Appendix III: Scope and Methodology 

To conduct our work, we examined relevant laws, regulations, and HHS 

documents related to the HPSA criteria and designation methodology that 

were in effect in 2005 for primary care HPSAs, and reviewed our prior 

work on the HPSA designation system. 

To determine the number of HPSAs, we interviewed officials from HRSA, 

who reported that precise, accurate, historical data on the total number of 

HPSAs were not available. Therefore, we designed a methodology that 

HRSA officials confirmed was reasonable for estimating the number of 

HPSAs designated as of September 2005. We used the following HRSA data 

sources for our methodology: 

• For geographic and population-group HPSAs, we obtained and analyzed

summary statistics on HPSA designations as of September 2005 from the 

Shortage Designation Branch within HRSA’s Bureau of Health Professions. 

• For facility HPSAs that were federal or state correctional institutions and 

public or nonprofit medical facilities, we reviewed a more detailed HRSA 

database of HPSAs designated as of September 2005, downloaded from 

HRSA’s Geospatial Data Warehouse.1

• For facility HPSAs that were health centers and rural health clinics with 

automatic facility HPSA designations, we analyzed HRSA’s data files of 

facilities with automatic HPSA designations as of September 2005. 

We also analyzed HRSA data on the HPSA scores of health centers and 

rural health clinics that received automatic HPSA designation to determine 

which of these facilities qualified for federal programs that required a 

minimum HPSA score as of September 2005. In addition, we reviewed data 

as of January 2006 downloaded from HRSA’s Geospatial Data Warehouse 

to identify the locations of geographic and population-group HPSAs and 

the HPSAs that were proposed to have their HPSA designations withdrawn 

 1

The HRSA Geospatial Data Warehouse provides a single point of access to HRSA 

programmatic information, related health resources, and demographic data for reporting

on HRSA activities. The data warehouse provides access to information for reporting and

mapping of HRSA data, including HPSAs. For more information, see HRSA, “HRSA

Geospatial Data Warehouse,” http://datawarehouse.hrsa.gov (downloaded Mar. 12, 2006).

We downloaded data on HPSA designations as of September 2005 from the data warehouse 

on October 27, 2005. We limited our analysis of the HPSA database downloaded from the 

data warehouse to those data elements that we determined, following discussion with 

HRSA officials, were reliable for our purposes. 

Page 45 GAO-07-84 Health Professional Shortage Areas
Appendix III: Scope and Methodology

because they no longer met the criteria or did not provide updated data in

support of their designations.2

We performed reliability checks on the HRSA data to identify potential 

duplicate entries or inconsistencies in the data—for example,

inconsistencies between HRSA’s published summary statistics and our 

analysis summarizing the data from HRSA’s Geospatial Data Warehouse—

and interviewed HRSA officials, Indian Health Service (IHS) officials, and 

officials from associations representing health centers and rural health 

clinics about the data. We accounted for limitations in the data by 

excluding from our analysis the lists of two categories of facility HPSAs—

public or nonprofit medical facilities and Alaska Native health centers—

that HRSA officials stated could have been duplicates of facilities in 

HRSA’s data of health centers that received automatic HPSA designation 

and that HRSA had not yet identified as duplicates and removed from its 

data.3

 In total, we excluded 136 public or nonprofit medical facilities and 

21 Alaska Native health centers. After taking these steps, we determined 

that the data were sufficiently reliable for our purposes. 

To obtain information on HPSA designation and federal programs that use 

HPSA designations, we reviewed Federal Register notices, laws, 

regulations, and documents from HHS’s Centers for Medicare & Medicaid 

Services (CMS), HRSA, and IHS, including HRSA’s National Health Service 

Corps (NHSC) summaries of the NHSC programs’ field strength at the end 

of fiscal year 2005, and we reviewed our prior work on these programs.4

To identify available research on the criteria used to designate HPSAs 

since we last reported on the criteria in 1995, we conducted a literature 

search of articles, studies, and reports—which we call reports—issued 

from January 1, 1995, through November 1, 2005. We focused our review 

on the HPSA criteria that were in effect both in 2002 when the Health Care 

Safety Net Amendments were enacted and at the time of our review. We 

 2

We downloaded data on HPSA designations as of January 2006 from HRSA’s Geospatial 

Data Warehouse on March 12, 2006. 

3

As of May 2006, the HRSA official responsible for designating HPSAs said that the agency

was in the process of removing the duplicate entries of health centers for Alaska Natives so

these facilities would be counted only once as a facility HPSA in HRSA’s databases. The 

HRSA official also reported that HRSA would remove duplicate public or nonprofit medical 

facilities when these HPSA designations were reviewed for continued eligibility.

4

We reviewed information from these same sources to obtain information on federal 

programs that use other federal designations of medical underservice. 

Page 46 GAO-07-84 Health Professional Shortage Areas
Appendix III: Scope and Methodology

performed the literature search of peer-reviewed reports using the 

ProQuest search engine and keywords that were related to the following

key elements of the HPSA designation criteria, including factors for 

determining areas with unusually high needs for primary medical care 

services:5

• ratio of population to primary care physicians, 

• indicators of the population with incomes below the poverty level (poverty 

or income), 

• infant mortality rate, 

• distance to health care services, and

• birth rate. 

We also identified reports published during that time frame related to the 

HPSA criteria or methodology from the bibliographies of relevant reports, 

recommendations from experts we interviewed, and our prior work. We 

did not independently assess the methods used in the reports we located.

Of the more than 340 reports located through the search, we identified 12

reports that we determined to be potentially relevant.6 After reviewing 

these 12 reports, we found 1 report in a peer-reviewed journal published 

from January 1, 1995, through November 1, 2005, that addressed the 

relationship between one of the key elements of the HPSA designation 

criteria (income) and primary care physician shortages or supply. We 

selected this report because it met the following criteria, in addition to the 

criteria outlined above: 

 5

The factors used to calculate the HPSA score were also generally represented in our 

keywords. 

6

We identified reports as potentially relevant if they addressed the relationship between

key elements of the HPSA designation criteria and primary care physician shortages or 

supply, including primary care disciplines, such as pediatrics. We determined the following 

types of reports not to be potentially relevant: those specific to other disciplines or 

professions, such as dental care, chiropractic care, specialty care, or nursing care; those 

related to recruitment and retention of physicians that focused on physician 

characteristics; those related to workforce projections; those using data from countries 

other than the United States or focusing on health care markets outside of the United 

States; and those with a narrow focus, such as on vaccine shortages. 

Page 47 GAO-07-84 Health Professional Shortage Areas
Appendix III: Scope and Methodology

• The report assessed the relationship between at least one key element of 

the HPSA designation criteria and primary care physician shortages or 

supply at the county, metropolitan statistical area, health service area, or

other local level.7

• The report used a definition of primary care similar to the definition used 

for the HPSA designation (e.g., general or family practice, general internal 

medicine, pediatrics, and obstetrics and gynecology). 

Of the 12 reports reviewed, 6 reports discussed aspects of the

methodology used to designate HPSAs: 1 issued by the Council on 

Graduate Medical Education (COGME), 1 issued by the Cecil G. Sheps 

Center for Health Services Research at the University of North Carolina at

Chapel Hill, and 4 published in peer-reviewed journals. 

To review the impact of the automatic designation on health centers and 

rural health clinics as facility HPSAs, we analyzed HRSA’s data on 

automatic HPSA designations and their associated scores. We also 

analyzed data on rural health clinics prepared by the Cecil G. Sheps Center 

for Health Services Research at the University of North Carolina at Chapel 

Hill for HRSA’s Office of Rural Health Policy, which used 2003 and 2004 

CMS data on rural health clinics and 2005 HRSA data on HPSAs. However, 

limitations in these data prevented us from determining exactly how many 

health centers and rural health clinics benefited when all health centers 

and certain rural health clinics received automatic designation as a result 

of the provision included in the Health Care Safety Net Amendments of 

2002. For example, the available data did not include sufficient geographic 

information to determine which of these facilities were located in 

geographic or population-group HPSAs before receiving automatic 

designation as facility HPSAs. Because of the data limitations, we also 

interviewed HHS officials in HRSA’s Office of Rural Health Policy and

Bureau of Primary Health Care, as well as officials from the National 

Association of Community Health Centers and the National Association of 

Rural Health Clinics, to discuss the impact of the automatic designation. 

We performed our work from August 2005 through September 2006 in 

accordance with generally accepted government auditing standards. 

 7

We excluded reports that used state-level data because these data are not necessarily 

applicable to smaller geographic units such as counties, and HPSAs are often based on

county boundaries or parts of counties.

Page 48 GAO-07-84 Health Professional Shortage Areas
Appendix IV: Federal Programs Using Health 

Professional Shortage Area and Other 

Designations of Underservice 

Various federal programs have used the HPSA, MUA, MUP or other 

designations, such as medically underserved communities, to allocate

resources, such as scholarships or grants, or to provide benefits, such as 

the waiver of requirements associated with a foreign physician’s visa (see

table 2). 

Table 2: Programs and Administering Agencies That Used HPSA, MUA, MUP or Other Designations to Allocate Resources or

Provide Benefits in Fiscal Year 2005 

Program 

Agency administering

program or benefit 

Resource allocated or

benefit provided

Federal funding 

informationa

Designation(s) used

by program 

Consolidated health 

center program

HRSA and CMS Awards grants for operation 

of health centers and other 

activities; provides benefits 

associated with federally 

qualified health center status, 

including eligibility to 

participate in a drug discount 

program and to receive 

reimbursement from 

Medicare and Medicaid using

special payment 

mechanisms, which serve as

an incentive for becoming a 

health center. 

$1,734 million 

(funding from 

FY 2005 

appropriations for 

HRSA)b

MUA 

MUP 

Federally qualified health 

center look-alike program 

HRSA and CMS Provides benefits associated

with federally qualified health 

center status, including 

eligibility to participate in a 

drug discount program and to

receive reimbursement from 

Medicare and Medicaid using

special payment 

mechanisms, which serve as

an incentive for becoming a 

health center. 

b

MUA 

MUP 

Indian Health Scholarship

Program 

IHS Awards American Indian and 

Alaska Native students with 

scholarships for service in 

certain practices in HPSAs or 

other practice locations 

authorized by statute.c

$9 million 

(funding from 

FY 2005 

appropriations for 

IHS) 

HPSAc

Appendix IV: Federal Programs Using Health 

Professional Shortage Area and Other 

Designations of Underservice 

Page 49 GAO-07-84 Health Professional Shortage Areas
Appendix IV: Federal Programs Using Health 

Professional Shortage Area and Other 

Designations of Underservice 

Program 

Agency administering

program or benefit 

Resource allocated or

benefit provided

Federal funding 

informationa

Designation(s) used

by program 

J-1 visa waivers for 

physicians at the request 

of federal agencies 

(3 programs) 

Department of Homeland

Security’s U.S. Citizenship 

and Immigration Services 

(USCIS), Department of 

State, Appalachian Regional 

Commission, Delta Regional 

Authority, HHS’s Office of 

Global Health Affairs, and 

HRSAd 

Waives requirement for 

certain foreign physicians to 

return to their home country 

or country of last legal 

residence for 2 years after 

graduate medical education 

at the request of an 

interested federal agency in 

exchange for at least 3 years 

of service in an area 

designated by the Secretary 

of Health and Human 

Services as having a 

shortage of health 

professionals. 

Not applicable HPSAe

MUA 

MUP 

J-1 visa waivers for 

physicians at the request 

of state health 

departments (also known 

as the Conrad Program) 

USCIS, Department of State, 

state health departmentsd

Waives requirement for 

certain foreign physicians to 

return to their home country 

or country of last legal 

residence for 2 years after 

graduate medical education 

in exchange for at least 3 

years of service in an area 

designated by the Secretary 

of Health and Human 

Services as having a 

shortage of health 

professionals. Limited to 30

waivers per state per year. 

Up to five waivers may be for 

physicians to practice outside 

of shortage areas as long as 

they practice in a facility that 

serves patients residing in 

such areas. 

Not applicable HPSA:

f

Practice in a HPSA or 

treating the residents 

of HPSAs 

MUA: 

Practice in an MUA or 

treating the residents 

of MUAs 

MUP: 

Practice in an MUP or 

treating the residents 

of MUPs 

Medicare Incentive 

Payment program 

CMS Provides 10 percent bonus 

payment on Medicare 

payments for physician

services in geographic 

HPSAs. 

$148 million 

(FY 2005 Medicare 

expenditures) 

HPSA: 

Geographic HPSAs 

only 

National Health Service 

Corps (4 programs)g

HRSA Awards scholarships to or 

provides money to repay 

educational loans of students 

and health professionals in

exchange for at least 2 years 

of service in a HPSA; 

supports commissioned 

officers of the U.S. Public 

Health Service to serve for 

3 years in the neediest 

HPSAs. 

$131 million 

(funding from 

FY 2005 

appropriations for 

HRSA) 

HPSA 

Page 50 GAO-07-84 Health Professional Shortage Areas
Appendix IV: Federal Programs Using Health 

Professional Shortage Area and Other 

Designations of Underservice 

Program 

Agency administering

program or benefit 

Resource allocated or

benefit provided

Federal funding 

informationa

Designation(s) used

by program 

National Interest Waivers 

for Immigrant Physicians 

USCIS Waives the job offer 

requirement placed on

certain immigrants, including 

physicians who agree to 

practice in a HPSA, an MUA, 

an MUP, or at Department of 

Veterans Affairs facilities.h

Not applicable HPSA: 

Geographic HPSAs 

only 

MUA

Rural Health Clinic 

program 

CMS Provides special Medicare 

and Medicaid payment 

mechanisms for rural health 

clinics, which serve as an 

incentive for becoming a 

rural health clinic. 

$413 million 

(2004 Medicare 

expenditures);i

$333 million 

(FY 2004 Medicaid 

expenditures)i

HPSA: 

Rural geographic and 

population-group 

HPSAs only 

MUA: 

Rural MUAs only 

Other: 

Rural areas 

designated by a 

state’s governor as 

shortage areas

Scholarships for 

Disadvantaged Students 

Program 

HRSA Awards grants to health 

professions schools to 

provide scholarships to fulltime, financially needy 

students from disadvantaged

backgrounds enrolled in

eligible health professions or 

nursing programs. Funding 

priority is given to schools 

applying for the funding 

based on the proportion of 

graduating students going 

into primary care, the 

proportion of 

underrepresented minority 

students, and the proportion

of graduates working in

medically underserved 

communities.j, k

$47 million 

(funding from

FY 2005 

appropriations for 

HRSA) 

HPSA 

MUA 

MUP 

Other: 

Other medically

underserved 

communitiesk

Page 51 GAO-07-84 Health Professional Shortage Areas
Appendix IV: Federal Programs Using Health 

Professional Shortage Area and Other 

Designations of Underservice 

Program 

Agency administering

program or benefit 

Resource allocated or

benefit provided

Federal funding 

informationa

Designation(s) used

by program 

Title VII health 

professions education 

and training grant 

programsl

 (16 programs) 

HRSA Provides grants for health 

professions education and 

training programs. Funding 

preference is given to 

applicants that (1) place a 

high or increasing number of 

graduates or program 

completers in settings having 

the principal focus of serving 

medically underserved 

communities or (2) have 

25 percent or more of their 

graduates in full-time practice

settings in medically 

underserved communities 

and meet other statutory 

requirements.k, m

$165 million 

(funding from

FY 2005 

appropriations for 

HRSA) 

HPSA 

MUA 

MUP 

Other: 

Other medically

underserved 

communitiesk

Title VIII nursing 

education programsn 

(2 programs) 

HRSA Provides grants to institutions

to provide financial support 

through traineeships for 

registered nurses enrolled in 

advanced education nursing 

programs or in a master’s 

degree nurse anesthesia 

program. In awarding grants, 

a funding preference is given 

to applicants whose projects 

will substantially benefit rural 

or underserved populations, 

using sites identified under 

the definition of medically 

underserved community as 

proxies, and gives special 

consideration for applicants 

with students who have 

committed to practicing in

HPSAs after graduation.k, o

$17 million 

(funding from 

FY 2005 

appropriations for 

HRSA) 

HPSA 

MUA 

MUP 

Other: 

Other medically

underserved 

communitiesk

Source: GAO analysis of HHS and other federal and state agency information. 

Note: In addition to the programs included in the table, other programs, including rural health grant 

programs administered by HRSA, have used the HPSA designation to some degree in allocating 

resources. For example, in fiscal year 2005, HRSA’s announcement for rural health network 

development grants stated that a funding preference would be given to those qualified applicants 

where the service area was located in a designated HPSA, was a medically underserved community, 

or served medically underserved populations. HRSA does not maintain a list of all programs using the

HPSA designation to allocate resources or provide benefits.

a

Funding amounts from HRSA and IHS reflect fiscal year 2005 appropriations or budget authority as

reported in the agencies’ fiscal year 2006 budget justifications and provided by agency officials. 

Budget authority is the authority provided by federal law to enter into financial obligations that will 

result in future outlays involving federal government funds. Budget authority includes appropriations 

and also includes the authority to borrow, enter into contracts, or to obligate and expend offsetting 

receipts and collections. Funding amounts from CMS reflect expenditure amounts under the Medicare 

and Medicaid programs from data in reports provided by CMS officials. 

Page 52 GAO-07-84 Health Professional Shortage Areas
Appendix IV: Federal Programs Using Health 

Professional Shortage Area and Other 

Designations of Underservice 

b

According to CMS officials, although data on Medicare and Medicaid payments to federally qualified 

health centers are available, data on expenditures for specific types of health centers, such as

consolidated health centers or federally qualified health center look-alikes, are not available. Data 

from reports provided by CMS officials show that in 2004, the most recent year for which complete 

data were available, Medicare payments to federally qualified health centers totaled about 

$278 million; in fiscal year 2004, the most recent year for which data were available, Medicaid 

payments to federally qualified health centers totaled about $778 million. 

c

Scholarship recipients must fulfill a service requirement by, for example, being engaged in full-time 

private practice in a HPSA addressing the health care needs of a substantial number of Indians.

Other types of service opportunities are also available for scholarship recipients. 

d

A federal agency or state (including the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin 

Islands) can request J-1 visa waivers for physicians who entered the United States for graduate 

medical education under the Department of State’s exchange visitor program. After being 

recommended by the Department of State, waivers are granted by USCIS. Three federal agencies—

HHS, Appalachian Regional Commission, and Delta Regional Authority—requested waivers for 

physicians to practice in underserved areas in fiscal year 2005. Also in fiscal year 2005, all 50 states, 

the District of Columbia, and Guam requested J-1 visa waivers for physicians to practice in facilities

located in or treating residents of underserved areas under a provision of the Immigration and 

Nationality Act, also known as the Conrad Program. 

e

The Appalachian Regional Commission’s and HHS’s J-1 visa waiver programs require waiver 

physicians to practice in HPSAs. The Delta Regional Authority’s J-1 visa waiver program requires 

waiver physicians to practice in HPSAs, MUAs or MUPs. 

f

Individual state requirements may vary. For example, one state may require J-1 visa waiver 

physicians to practice in HPSAs, while other states may require them to practice in HPSAs, MUAs, or

MUPs. 

g

National Health Service Corps programs include the Scholarship Program, federal Loan Repayment 

Program, State Loan Repayment Program, and Ready Responders.

h

8 U.S.C. § 1153(b)(2)(B)(ii), 8 C.F.R. § 204.12 (2006). 

i

According to CMS officials, the most recent completed year for which data on rural health clinics were 

available was 2004 for Medicare payments and fiscal year 2004 for Medicaid payments. 

j

Funding priorities are factors that provide a grant applicant with a fixed amount of additional rating 

points, which could place the applicant in a more favorable position to receive a grant award than the 

applicant would be without the additional rating points. 

k

A medically underserved community is an urban or rural area or population that (1) is eligible for 

HPSA designation; (2) is eligible to be served by a community health center, migrant health center, or 

a grantee serving residents of public housing or the homeless; (3) has a shortage of personal health 

services, as determined under criteria issued by the Secretary of Health and Human Services relating 

to rural health clinics; or (4) is designated by a state governor (in consultation with the medical 

community) as a shortage area or medically underserved community. 

l

Includes 15 health professions education programs authorized under title VII of the Public Health 

Service Act that have a funding preference for applicants that place a high or increasing number of 

graduates or those completing the program in settings having the principal focus of serving medically 

underserved communities, including (1) programs for training in family medicine, general internal 

medicine, general pediatrics, physician assistants, general dentistry, or pediatric dentistry; 

(2) programs for area health education centers; (3) Health Education and Training Centers program; 

(4) Quentin N. Burdick Program for Rural Interdisciplinary Training; (5) programs for allied health 

projects and other disciplines; and (6) geriatric education programs. In addition to these 15 programs, 

1 additional grant program authorized under title VII of the Public Health Service Act, Health 

Administration Traineeships and Special Projects, has a funding preference for applicants that have 

not less than 25 percent of their graduates in full-time practice settings in medically underserved 

communities, that recruit and admit students from medically underserved communities, that have 

established relationships with public and nonprofit providers of health care in the community involved, 

and that emphasize employment with public and nonprofit entities in their training of students. 

Page 53 GAO-07-84 Health Professional Shortage Areas
Appendix IV: Federal Programs Using Health 

Professional Shortage Area and Other 

Designations of Underservice 

m

A funding preference is also available to applicants implementing new programs if they meet at least 

four of seven statutory criteria. 

n

Includes the Advanced Education Nursing Traineeship Program and Nurse Anesthetist Traineeship 

Program. 

o

The funding preference also applies to applicants that will help meet public health nursing needs in 

state or local health departments. Special considerations are factors considered in making funding 

decisions that are not review criteria, preferences, or priorities, for example, ensuring that there is an 

equitable geographic distribution of grant recipients. 

Page 54 GAO-07-84 Health Professional Shortage Areas
Appendix V: Comments from the Department Appendix V of Health and Human Services : Comments from the Department 

of Health and Human Services 

Page 55 GAO-07-84 Health Professional Shortage Areas
Appendix V: Comments from the Department 

of Health and Human Services 

Page 56 GAO-07-84 Health Professional Shortage Areas
Appendix V: Comments from the Department 

of Health and Human Services 

Page 57 GAO-07-84 Health Professional Shortage Areas
Appendix V: Comments from the Department 

of Health and Human Services 

Page 58 GAO-07-84 Health Professional Shortage Areas
Appendix VI: GAO Contact and Staff Acknowledgments 

Page 59 GAO-07-84

Appendix VI: GAO Contact and Staff 

Acknowledgments 

GAO Contact Leslie G. Aronovitz, (312) 220-7600 or aronovitzl@gao.gov

In addition to the person named above, Kim Yamane, Assistant Director; 

Ellen W. Chu; Jennifer DeYoung; and Julian Klazkin made key 

contributions to this report. 

Acknowledgments 

Health Professional Shortage Areas
Related GAO Products Related GAO Products 

Foreign Physicians: Preliminary Findings on the Use of J-1 Visa 

Waivers to Practice in Underserved Areas. GAO-06-773T. Washington,

D.C.: May 18, 2006. 

Health Professions Education Programs: Action Still Needed to Measure 

Impact. GAO-06-55. Washington, D.C.: February 28, 2006. 

Health Centers: Competition for Grants and Efforts to Measure 

Performance Have Increased. GAO-05-645. Washington, D.C.: July 13, 

2005. 

Health Centers and Rural Clinics: State and Federal Implementation 

Issues for Medicaid’s New Payment System. GAO-05-452. Washington, 

D.C.: June 17, 2005. 

Health Workforce: Ensuring Adequate Supply and Distribution Remains

Challenging. GAO-01-1042T. Washington, D.C.: August 1, 2001. 

Health Care Access: Programs for Underserved Populations Could Be 

Improved. GAO/T-HEHS-00-81. Washington, D.C.: March 23, 2000. 

Physician Shortage Areas: Medicare Incentive Payments Not an 

Effective Approach to Improve Access. GAO/HEHS-99-36. Washington,

D.C.: February 26, 1999. 

Health Care Access: Opportunities to Target Programs and Improve 

Accountability. GAO/T-HEHS-97-204. Washington, D.C.: September 11, 

1997. 

Rural Health Clinics: Rising Program Expenditures Not Focused on 

Improving Care in Isolated Areas. GAO/T-HEHS-97-65. Washington, D.C.: 

February 13, 1997. 

National Health Service Corps: Opportunities to Stretch Scarce Dollars 

and Improve Provider Placement. GAO/HEHS-96-28. Washington, D.C.: 

November 24, 1995. 

Health Care Shortage Areas: Designations Not a Useful Tool for 

Directing Resources to the Underserved. GAO/HEHS-95-200.Washington,

D.C.: September 8, 1995. 

(290486) Page 60 GAO-07-84 Health Professional Shortage Areas
GAO’s Mission The Government Accountability Office, the audit, evaluation and 

investigative arm of Congress, exists to support Congress in meeting its 

constitutional responsibilities and to help improve the performance and 

accountability of the federal government for the American people. GAO 

examines the use of public funds; evaluates federal programs and policies; 

and provides analyses, recommendations, and other assistance to help

Congress make informed oversight, policy, and funding decisions. GAO’s 

commitment to good government is reflected in its core values of 

accountability, integrity, and reliability. 

The fastest and easiest way to obtain copies of GAO documents at no cost

is through GAO’s Web site (www.gao.gov). Each weekday, GAO posts 

newly released reports, testimony, and correspondence on its Web site. To

have GAO e-mail you a list of newly posted products every afternoon, go 

to www.gao.gov and select “Subscribe to Updates.” 

The first copy of each printed report is free. Additional copies are $2 each. 

A check or money order should be made out to the Superintendent of 

Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 

more copies mailed to a single address are discounted 25 percent. Orders 

should be sent to: 

U.S. Government Accountability Office 

441 G Street NW, Room LM 

Washington, D.C. 20548 

To order by Phone: Voice: (202) 512-6000 

TDD: (202) 512-2537 

Fax: (202) 512-6061 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470 

Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 

U.S. Government Accountability Office, 441 G Street NW, Room 7125 

Washington, D.C. 20548 

Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, D.C. 20548 

Obtaining Copies of 

GAO Reports and 

Testimony

Order by Mail or Phone 

To Report Fraud,

Waste, and Abuse in 

Federal Programs 

Congressional 

Relations 

Public Affairs 

PRINTED ON RECYCLED PAPER