Federally Qualified Community Health Centers - aka FQHCs, Community Health Centers (CHCs), Neighborhood Health Centers, or simply Health Centers - are public and private non-profit healthcare organizations funded under Section 330 of the Public Health Service Act, directed by a consumer board of directors, and complying with Federal requirements to serve medically underserved populations. In 2017 FQHCs saw more than 27 million individual patients in the United States, of whom approximately two million were seen by health centers in New York State (Bureau of Primary Health Care 2017). Despite these staggering figures, relatively little academic work has investigated how these health centers operate at an administrative and bureaucratic level. To study the bureaucratic practice of FQHCs, this research utilizes an ethnographic approach, conducted over a period of three-plus years at a FQHC in New York State (pseudonymously called Care Center). It incorporates structured interviews, informal interviews, the collection of fieldnotes, and participant observation, as well as qualitative data analysis. Collectively this research approach produces a complex portrait of how bureaucratic activity at the specific FQHC field site was organized, conducted, and structured within the context of substantial growth in the FQHC program. The setting of the study offers a unique opportunity to explore the implications of this bureaucratic activity on FQHCs and, by extension, other safety-net healthcare institutions in the United States. This research also delivers a substantial historical account of the emergence of the FQHC program in order to connect that account to the broader arc of healthcare history in the United States during the 20th and 21st centuries. This connection demonstrates the linkages between specific aspects of FQHC bureaucratic practice and larger trends in health care more generally. The emphasis on “need” as a discursive object that is frequently referenced and utilized as an organizing mechanism by FQHC bureaucracy allows us to better understand and problematize the use of need as a criterion for organizational growth.