New York City, November 26, 2002—Community Health Centers (CHCs) often find it difficult or impossible to arrange and refer their uninsured patients for off-site care, such as needed diagnostic, specialty, and behavioral health care services, according to new research supported by The Commonwealth Fund and published in the journal Health Affairs. CHCs are a vital source of primary and preventive health care for the nation's uninsured. Because of limits on what they are able to provide on site, however, CHCs must typically refer patients for diagnostic tests such as mammograms and colonoscopies, or for more specialized physician services, such as cardiology. Despite the considerable efforts of staff to obtain referrals and negotiate reduced fees, uninsured patients often go without needed care. The survey of CHC executive directors and medical directors revealed that CHCs are twice as likely to be able to provide referrals outside the CHC for their insured patients compared with their uninsured patients. CHC medical directors also reported they are less often able to obtain nonemergency hospital admissions and less often able to obtain specialty referrals for their uninsured patients. The findings point to the limits of the safety net system in providing care for the uninsured, and the increasing strain on resources as the number of uninsured Americans rises. "Community health centers are a mainstay of our health care system, providing accessible and affordable primary health care to neighborhood residents with low incomes," said Karen Davis, president of The Commonwealth Fund. "But inadequate funding is leaving significant holes in this critical part of the safety net." In "Exploring the Limits of the Safety Net: Community Health Centers and Care for the Uninsured," in the November/December issue of Health Affairs, Michael K. Gusmano, associate director of the World Cities Project at the International Longevity Center-USA, and Gerry Fairbrother and Heidi Park, both of the division of Health and Science Policy at the New York Academy of Medicine, report findings from a survey of executive directors and medical directors at 20 urban and rural CHCs in 10 states. In the CHCs studied, 43% of the patient population were uninsured and 34% were Medicaid beneficiaries. Three of five (60%) patients had incomes below the federal poverty level, and one-fifth (21%) had incomes of 100-200 percent of the poverty level. CHCs use a sliding fee scale for patients who cannot afford to pay for their care, and most will provide care for patients who cannot afford to pay the fee. In the case of medical, dental, and other health services that CHCs are funded to provide on site, the CHC medical directors indicated that they are able to provide essentially the same level of care for their uninsured and their insured patients. However, for services not provided on site, most CHC medical directors reported that they refer patients to other providers but do not pay for these services. The majority of CHCs said they refer cardiology patients to providers off-site and refer off-site for mammograms. Medical directors reported they were more likely to have difficulties referring their uninsured patients for services off-site. All of the medical directors said they could provide referrals for their insured patients, but only 59 percent indicated they could usually secure referrals for their uninsured patients. The authors note that the Bush Administration's plan to double the number of CHCs by the year 2006 will provided needed expansion of primary care to uninsured Americans, but they warn that without a substantial increase in their budgets CHCs will not be able to address the limitations they face in providing additional services. "Without a strong health insurance base, CHCs will have difficulty meeting even their primary care mission, much less providing specialty referrals," said Sara Rosenbaum, interim chair, Department of Health Policy at the George Washington University Medical Center and author of other seminal safety net studies.