Objective This study describes strategies used by federally qualified health centers (FQHCs) to assist medically uninsured patients in obtaining specialty health care services.

Methods Qualitative methods were used to study strategies for obtaining specialty health care for uninsured patients. Data were gathered from 10 primary care clinicians at three FQHC clinics by means of 10 semistructured interviews, 23 brief interviews, and 45 h of direct observations. We captured additional data by studying cases of referred uninsured patients.

Results The following six strategies were identified: (1) quid pro quo – a specialist accepting the clinic’s medically uninsured patients was rewarded with referrals of the clinic’s insured patients; (2) over referral – clinicians referred insured patients whose needs could have been met at the FQHC; (3) brief hospitalization – when a specialist could not be obtained, high-risk patients were briefly hospitalized; (4) case building – diagnostic tests were conducted at the FQHC to justify a referral; (5) direct communication – communication between clinicians and specialists was necessary when requesting a referral; (6) specialty clinics – in return for conducting a specialty clinic at the FQHC, the specialist received all referrals of insured patients.

Conclusion Uninsured FQHC patients encountered difficulties accessing specialty health care, and in response, clinicians developed a range of innovative strategies.