{
  "study": {
    "slug": "medically-underserved-areas-designation-age-2026",
    "title": "America's medically underserved areas are a map drawn last century",
    "standfirst": "HRSA's map of America's medically underserved areas is old: of the 4,148 active MUA/MUP designations, 72.1% were made before 2000, the median dates to 1994, and 1,074 — one in four — share a single founding date in November 1978. A designation carries no expiration; it stays until withdrawn.",
    "desk": "access",
    "article_type": "Original Research",
    "published": "2026-06-16",
    "issue": 81,
    "doi": "10.5072/fonteum/medically-underserved-areas-designation-age-2026",
    "url": "https://fonteum.com/research/medically-underserved-areas-designation-age-2026",
    "methodology_version": "hrsa-mua-mup/v1"
  },
  "data_as_of": "2026-06-16",
  "datasets": [
    {
      "slug": "hrsa-hpsa",
      "name": "HRSA HPSA",
      "publisher": "HRSA — Health Professional Shortage Areas",
      "upstream_url": null
    }
  ],
  "key_findings": [
    {
      "number": "72.1%",
      "finding": "of the 4,148 active Medically Underserved Area / Population designations were made before 2000 — 2,991 of them. The median active designation dates to May 1994, and only 7.8% were designated in the last ten years. An MUA/MUP carries no fixed expiration; it stays in effect until HRSA withdraws it",
      "dataset": "hrsa-hpsa"
    },
    {
      "number": "1,074",
      "finding": "active designations — one in four (25.9%) — share a single designation date of November 1, 1978, the program's founding cohort. They have been designated for 47 years and 718 of them have no recorded update since the day they were designated",
      "dataset": "hrsa-hpsa"
    },
    {
      "number": "54.8",
      "finding": "is the average Index of Medical Underservice across the 3,808 standard designations that carry a published score, on the 0-to-100 scale where 62.0 or below qualifies. 2,313 of them sit in the narrow 55-62 band just under the cutoff; the index is computed once at designation and not refreshed",
      "dataset": "hrsa-hpsa"
    },
    {
      "number": "216",
      "finding": "active designations (140 areas and 76 populations) are Governor's Exceptions — designated despite not qualifying on the index, at a state governor's request. Among the 70 that carry a published score the average index is 72.0, above the 62.0 cutoff, exactly as the exception is built to allow",
      "dataset": "hrsa-hpsa"
    },
    {
      "number": "4,148",
      "finding": "active designated MUA/MUP rows make up the current map — 3,567 area-based (86.0%) and 581 population-based — snapshot dated 2026-05-28; a further 673 are withdrawn and 82 proposed for withdrawal. Every figure is a count over published designations; no individual provider is named, ranked, or scored",
      "dataset": "hrsa-hpsa"
    }
  ],
  "faqs": [
    {
      "q": "What is a Medically Underserved Area or Population?",
      "a": "A Medically Underserved Area (MUA) or Population (MUP) is a federal designation HRSA assigns to a geographic area or a specific population group that has too little access to primary care. It is scored on the Index of Medical Underservice, which combines primary-care physicians per 1,000 people, the infant mortality rate, the share of the population below poverty, and the share aged 65 and older. An area qualifies at an index of 62.0 or below."
    },
    {
      "q": "How is an MUA/MUP different from a Health Professional Shortage Area (HPSA)?",
      "a": "They are separate programs with separate rules. A HPSA measures the supply of a particular kind of clinician — primary care, dental, or mental health — and many HPSA designations are reviewed and can lapse. An MUA/MUP measures broader primary-care access through the Index of Medical Underservice, applies to areas and populations rather than disciplines, and carries no fixed expiration: it stays in effect until HRSA actively withdraws it. This study is about the MUA/MUP map specifically."
    },
    {
      "q": "Why are so many designations from the 1970s and 1990s?",
      "a": "Because MUA/MUP designations do not expire. Once an area is designated it remains on the active list until HRSA withdraws it, so designations accumulate rather than turning over. The single largest cohort — 1,074 active designations, one in four — was made on November 1, 1978, in the program's early implementation, and is still in effect today. The median active designation dates to May 1994."
    },
    {
      "q": "Does an old designation mean the area is no longer underserved?",
      "a": "Not necessarily, and this study makes no such claim. The Index of Medical Underservice is computed once at the time of designation and is not automatically refreshed, so the data records when an area was added to the map and on what score — not whether conditions there have improved or worsened since. An old designation may still reflect real need; it simply has not been re-measured in the published file."
    },
    {
      "q": "What is a Governor's Exception designation?",
      "a": "It is a designation made even though the area did not qualify on the Index of Medical Underservice. Under HRSA's rules a state governor can request a designation based on unusual local conditions that the standard formula does not capture. There are 216 active Governor's Exception designations — 140 areas and 76 populations — and among the 70 that carry a published score the average index is 72.0, above the 62.0 qualifying cutoff, which is exactly the situation the exception exists to handle."
    },
    {
      "q": "Which states have the most medically underserved designations?",
      "a": "California (213) and Texas (212) have the most active designations, followed by Illinois (176) and Georgia (168). The age of the map varies sharply by state: North Carolina and Georgia both run a median designation date of 1978 — 95.6% of North Carolina's and 82.7% of Georgia's designations predate 2000 — while Florida is the outlier with a median of 2001 and only 30.2% predating 2000."
    },
    {
      "q": "Is a designation a judgment about the providers in that area?",
      "a": "No. A Medically Underserved Area or Population designation is a workforce-policy instrument about access to care across a place or a group of people. It says nothing about the quality, conduct, or standing of any clinician who practices there, and this study names, ranks, and scores no individual provider. Every figure is a count over published designations."
    },
    {
      "q": "Can I reproduce these figures?",
      "a": "Yes. Every number is a direct count over the public hrsa_shortage_areas table, filtered to MUA/MUP rows, snapshot dated 2026-05-28 — with no modeling. The exact SQL for the decade distribution, the 1978 cohort, the Index of Medical Underservice bands, the Governor's Exception split, and the state breakdown is published in the reproducibility block below."
    }
  ],
  "citation": {
    "apa": "Fonteum Research. (2026, June 16). America's medically underserved areas are a map drawn last century. Fonteum Research, Issue 81. https://doi.org/10.5072/fonteum/medically-underserved-areas-designation-age-2026",
    "url": "https://fonteum.com/research/medically-underserved-areas-designation-age-2026"
  },
  "reproducible_sql": "-- America's Medically Underserved Areas and Populations (MUA/MUP) are an old\n-- map: most of the active designations were made last century and have never\n-- been updated since. Fully reproducible query.\n--\n-- Question: HRSA's Medically Underserved Area / Population (MUA/MUP) program is\n-- a SEPARATE designation system from the Health Professional Shortage Area\n-- (HPSA) program. An MUA/MUP is scored once on the Index of Medical Underservice\n-- (IMU) — a 0-to-100 scale combining primary-care physicians per 1,000 people,\n-- the infant mortality rate, the share of population below poverty, and the\n-- share age 65 and older — and a service area qualifies at an IMU of 62.0 or\n-- below. Unlike many HPSA designations, an MUA/MUP carries NO fixed expiration:\n-- it stays in effect until HRSA actively withdraws it. So how old is the active\n-- map, and how current is the index behind it?\n--\n-- The lead figure: of the 4,148 currently DESIGNATED MUA/MUP rows, 2,991 (72.1%)\n-- were designated before 2000, the median designation dates to May 1994, and\n-- 1,074 of them — one in four — share a single founding-cohort date of\n-- 1978-11-01. A designation is a workforce-policy instrument, NOT a quality,\n-- fraud, or wrongdoing signal of any kind, and names no individual provider.\n--\n-- Source:\n--   public.hrsa_shortage_areas, rows WHERE designation_kind = 'mua_mup' — HRSA's\n--     Medically Underserved Areas/Populations file, published via data.hrsa.gov.\n--     4,903 MUA/MUP rows; snapshot last_update_date max 2026-05-28. Public,\n--     read-only. License: US-Government-Works (17 U.S.C. Sec. 105).\n--     methodology_version = 'hrsa-mua-mup/v1'.\n--\n-- Universe: this study reads the ACTIVE designations — status = 'Designated'\n--   (4,148 rows) — the current MUA/MUP map. Withdrawn (673) and proposed-for-\n--   withdrawal (82) rows are reconciled in query (1) but excluded from the\n--   active-map figures. The same active-designation universe is used by the\n--   companion HRSA shortage-area studies.\n--\n-- IMU note: the published IMU is stored in `score`. 270 active designations\n--   carry score = 0, which we read as \"no IMU published\" (nearly all are pre-2010\n--   designations) and EXCLUDE from IMU averages — we never treat a missing score\n--   as a literal zero. A higher IMU means LESS underservice; 62.0 is the cutoff.\n\n-- ============================================================================\n-- (1) Universe reconciliation — the MUA/MUP file at a glance.\n-- ============================================================================\nSELECT\n  count(*)                                                          AS mua_mup_rows,\n  count(*) FILTER (WHERE status = 'Designated')                     AS designated,\n  count(*) FILTER (WHERE status = 'Withdrawn')                      AS withdrawn,\n  count(*) FILTER (WHERE status = 'Proposed For Withdrawal')        AS proposed_withdrawal,\n  min(designation_date)                                            AS earliest_designation,\n  max(designation_date)                                            AS latest_designation,\n  max(last_update_date)                                            AS snapshot\nFROM public.hrsa_shortage_areas\nWHERE designation_kind = 'mua_mup';\n--  mua_mup_rows 4,903 · designated 4,148 · withdrawn 673 · proposed_withdrawal 82\n--  earliest_designation 1977-03-11 · latest_designation 2026-05-28 · snapshot 2026-05-28\n\n-- ============================================================================\n-- (2) HEADLINE: how OLD the active map is. Decade of designation, plus the\n--     share predating 2000 and the share from the last decade. 72.1% predate\n--     2000; the median active designation dates to 1994-05-11; only 7.8% were\n--     designated in the last ten years.\n-- ============================================================================\nWITH d AS (\n  SELECT * FROM public.hrsa_shortage_areas\n  WHERE designation_kind = 'mua_mup' AND status = 'Designated'\n)\nSELECT\n  (floor(extract(year FROM designation_date) / 10) * 10)::int || 's'  AS decade,\n  count(*)                                                          AS designations,\n  round(100.0 * count(*) / sum(count(*)) OVER (), 1)                AS pct_of_active\nFROM d\nGROUP BY decade\nORDER BY decade;\n--  1970s  1,090  26.3%\n--  1980s    323   7.8%\n--  1990s  1,578  38.0%\n--  2000s    613  14.8%\n--  2010s    387   9.3%\n--  2020s    157   3.8%\n--\n-- Summary figures over the same active set (4,148 rows):\n--   designated before 2000-01-01 ............... 2,991 (72.1%)\n--   designated 2016-01-01 onward (last decade) ...  324 ( 7.8%)\n--   median designation_date .................... 1994-05-11\n--   designations whose last_update_date equals\n--     their original designation_date .......... 3,030 (73.0% — no recorded change since)\n--   median last_update_date .................... 1994-06-03\n\n-- ============================================================================\n-- (3) The 1978 founding cohort. A single designation date — November 1, 1978 —\n--     accounts for 1,074 of the 4,148 active designations (25.9%): one in four\n--     of today's medically underserved areas was designated on one day, 47 years\n--     ago, and is still in effect. 718 of those 1,074 have never been updated since.\n-- ============================================================================\nWITH d AS (\n  SELECT * FROM public.hrsa_shortage_areas\n  WHERE designation_kind = 'mua_mup' AND status = 'Designated'\n)\nSELECT\n  designation_date,\n  count(*)                                                          AS designations,\n  round(100.0 * count(*) / sum(count(*)) OVER (), 1)                AS pct_of_active\nFROM d\nGROUP BY designation_date\nORDER BY designations DESC\nLIMIT 6;\n--  1978-11-01  1,074  25.9%   <- the founding cohort, still designated\n--  1994-05-11    309   7.4%\n--  1994-05-12    285   6.9%\n--  1994-05-04     58   1.4%\n--  1994-04-12     44   1.1%\n--  1994-05-09     34   0.8%\n\n-- ============================================================================\n-- (4) The Index of Medical Underservice behind the active map. Among the 3,808\n--     standard (non-exception) designations that carry a published IMU, the\n--     average is 54.8 on the 0-to-100 scale where 62.0 or below qualifies; 2,313\n--     of them sit in the narrow 55-62 band just under the cutoff. The IMU is\n--     computed once at designation and is not refreshed, so for a file whose\n--     median designation is 1994 these are largely 1990s index values. 270 active\n--     designations carry no published IMU at all (score = 0) and are excluded here.\n-- ============================================================================\nWITH d AS (\n  SELECT * FROM public.hrsa_shortage_areas\n  WHERE designation_kind = 'mua_mup' AND status = 'Designated'\n    AND designation_type NOT LIKE '%Exception%'\n    AND score > 0\n)\nSELECT\n  CASE\n    WHEN score <= 40 THEN 'a. IMU <= 40 (deepest need)'\n    WHEN score <= 50 THEN 'b. IMU 40-50'\n    WHEN score <= 55 THEN 'c. IMU 50-55'\n    WHEN score <= 62 THEN 'd. IMU 55-62 (just under cutoff)'\n    ELSE                   'e. IMU > 62 (above cutoff)'\n  END                                                               AS imu_band,\n  count(*)                                                          AS designations\nFROM d\nGROUP BY imu_band\nORDER BY imu_band;\n--  a. IMU <= 40 (deepest need) ......  166\n--  b. IMU 40-50 .....................  546\n--  c. IMU 50-55 .....................  777\n--  d. IMU 55-62 (just under cutoff) . 2,313   <- 60.8% of scored standard designations\n--  e. IMU > 62 (above cutoff) .......    6\n--  (mean IMU across these 3,808 scored standard designations = 54.8; range 18.1-74.7.)\n\n-- ============================================================================\n-- (5) The Governor's Exception. 216 active designations (140 areas + 76\n--     populations) were made despite not qualifying on the index — at a state\n--     governor's request under HRSA's exception process. Among the 70 of them\n--     that carry a published IMU, the average is 72.0, above the 62.0 cutoff,\n--     exactly as the exception is designed to allow.\n-- ============================================================================\nWITH d AS (\n  SELECT\n    (designation_type LIKE '%Exception%')                          AS is_governors_exception,\n    score\n  FROM public.hrsa_shortage_areas\n  WHERE designation_kind = 'mua_mup' AND status = 'Designated'\n)\nSELECT\n  is_governors_exception,\n  count(*)                                                          AS designations,\n  count(*) FILTER (WHERE score > 0)                                 AS with_published_imu,\n  round(avg(score) FILTER (WHERE score > 0), 1)                     AS avg_imu_scored\nFROM d\nGROUP BY is_governors_exception\nORDER BY is_governors_exception;\n--  standard           3,932 · 3,808 scored · avg IMU 54.8\n--  governors_exception  216 ·    70 scored · avg IMU 72.0  (above the 62.0 cutoff)\n\n-- ============================================================================\n-- (6) WHERE the active designations are, and how old each state's map is. Top\n--     12 states by count, with each state's median designation date and the\n--     share predating 2000. California and Texas lead by count, but North\n--     Carolina and Georgia run a median date of 1978; Florida is the outlier\n--     with a 2001 median and only 30.2% predating 2000.\n-- ============================================================================\nWITH d AS (\n  SELECT * FROM public.hrsa_shortage_areas\n  WHERE designation_kind = 'mua_mup' AND status = 'Designated' AND state IS NOT NULL\n)\nSELECT\n  state,\n  count(*)                                                          AS designations,\n  percentile_disc(0.5) WITHIN GROUP (ORDER BY designation_date)     AS median_designation_date,\n  round(100.0 * count(*) FILTER (WHERE designation_date < '2000-01-01') / count(*), 1) AS pct_pre_2000\nFROM d\nGROUP BY state\nORDER BY designations DESC\nLIMIT 12;\n--  CA 213  median 1994-08-01  69.5% pre-2000\n--  TX 212  median 1984-07-03  65.1%\n--  IL 176  median 1994-05-18  72.2%\n--  GA 168  median 1978-11-01  82.7%\n--  PA 156  median 1994-05-12  82.7%\n--  OH 137  median 1994-05-12  79.6%\n--  NY 132  median 1994-05-04  82.6%\n--  FL 129  median 2001-09-26  30.2%   <- the outlier: a refreshed map\n--  MO 123  median 1992-08-04  94.3%\n--  MI 115  median 1994-05-27  67.8%\n--  NC 113  median 1978-11-01  95.6%\n--  KY 112  median 1990-11-23  67.0%\n\n-- ============================================================================\n-- (7) Structure: areas vs populations, and the exception split. 86.0% of the\n--     active map is area-based (MUA), 14.0% population-based (MUP).\n-- ============================================================================\nSELECT\n  designation_type,\n  count(*)                                                          AS designations,\n  round(100.0 * count(*) / sum(count(*)) OVER (), 1)                AS pct_of_active\nFROM public.hrsa_shortage_areas\nWHERE designation_kind = 'mua_mup' AND status = 'Designated'\nGROUP BY designation_type\nORDER BY designations DESC;\n--  Medically Underserved Area .......................... 3,427  82.6%\n--  Medically Underserved Population .....................  505  12.2%\n--  Medically Underserved Area - Governor's Exception ....  140   3.4%\n--  Medically Underserved Population - Governor's Exception   76   1.8%\n--  (area-based = MUA + MUA-exception = 3,567, 86.0%; population-based = 581, 14.0%.)",
  "license": "U.S. Government Works (federal sources; 17 U.S.C. §105)",
  "generated_by": "Fonteum — https://fonteum.com",
  "notes": "Aggregate, source-traced figures frozen to the snapshot above. Reproduce by running reproducible_sql against the cited federal dataset; no per-entity records are included."
}