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The American Journal of Managed Care March 2019
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Specialty Care Access for Medicaid Enrollees in Expansion States
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Specialty Care Access for Medicaid Enrollees in Expansion States

Justin W. Timbie, PhD; Ashley M. Kranz, PhD; Ammarah Mahmud, MPH; and Cheryl L. Damberg, PhD
In a survey of community health center medical directors in 9 Medicaid expansion states and DC, nearly 60% reported difficulty obtaining new specialist visits and multiple access barriers on behalf of their patients.
CHCs reported difficulty accessing similar types of specialty care for both uninsured patients and Medicaid enrollees. Notably, substance use disorder (SUD) treatment specialists and dentists, whose services have historically been in high demand at CHCs, were rarely reported as the specialists who were most difficult to access through referrals, which others have speculated may be due to increased funding and attention for SUD treatment and Medicaid expansions, respectively.20,21

Among CHCs that reported specialty access problems, the majority had implemented strategies to access specialty care for their patients and help their patients make those appointments. To obtain specialty care for patients, most CHCs reported entering into agreements that specified the terms and expectations regarding referrals and engaging with specialty practices in health promotion and quality improvement initiatives, with fewer CHCs reporting use of e-consult systems and participation in data exchange with specialists. These findings highlight the range of strategies CHCs are pursuing, which are timely findings in light of HRSA’s August 2018 updated requirements that CHCs collaborate with specialists and document these efforts.22 Additionally, to promote patient attendance at appointments, many CHCs reported making appointments on behalf of patients, with fewer CHCs reporting use of reminder systems to help prevent their patients being “no-shows” to their specialty appointments. Because evidence suggests that patient reminders via phone or text message can help promote visit attendance,23 more CHCs should consider pursuing this strategy.


This cross-sectional survey did not include items about changes since Medicaid expansion and cannot make any causal conclusions about the impact of Medicaid expansion on changes in access to specialty care. Additional study limitations include nonresponse bias, which may have led us to either over- or understate actual levels of difficulty accessing specialty care. In addition, we may not have captured the full breadth of strategies that CHCs are using to secure specialty care for their patients. Additionally, further research is needed to determine if these findings differ for CHCs in states that did not expand Medicaid. Finally, although our survey did not include all Medicaid expansion states, we designed the sample to be geographically diverse.


Obtaining specialty care is a significant problem for uninsured patients and Medicaid patients seeking care from CHCs, the entry point to the US healthcare system for tens of millions of low-income patients. Despite using a wide range of strategies to achieve integrated systems of care with specialists in their communities, CHCs report few available specialists, low Medicaid payments, long travel times, and high cost-sharing burdens for patients as the greatest barriers to obtaining specialty care for their patients. Payment policies and network adequacy rules may need to be reexamined to reduce long-standing inequities in access to specialty care for our nation’s most vulnerable residents.

Author Affiliations:  RAND Corporation, Arlington, VA (JWT, AMK, AM), and Santa Monica, CA (CLD).

Source of Funding: This work was supported through the RAND Center of Excellence on Health System Performance, which is funded through a cooperative agreement (1U19HS024067-01) between the RAND Corporation and the Agency for Healthcare Research and Quality. The content and opinions expressed in this publication are solely the responsibility of the authors and do not reflect the official position of the Agency or HHS.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JWT, AMK, AM, CLD); acquisition of data (JWT, AMK, AM); analysis and interpretation of data (JWT, AMK); drafting of the manuscript (JWT, AMK, AM); critical revision of the manuscript for important intellectual content (JWT, AMK, AM, CLD); obtaining funding (JWT, CLD); and supervision (CLD).

Address Correspondence to: Ashley M. Kranz, PhD, RAND Corporation, 1200 S Hayes St, Arlington, VA 22202. Email:

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