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For example, community health centers are typically not able to perform diagnostic tests on site. The surveys reported that when a physician deemed a particular diagnostic test necessary, uninsured patients faced major difficulty in accessing the test 21 percent of the time, versus only 1 percent for insured patients. Those numbers were the same for medical-specialist referrals. The most dramatic discrepancy involved accessing high-tech services such as cardiac catheterizations. Here, 52 percent of the time, medical directors reported difficult access for uninsured patients, versus 10 percent for insured patients. Directors reported about 16 percent of the time that Medicaid patients confronted significant barriers in accessing these same services. Other examples include the following:

• Specialized services (e.g., chemotherapy): 30% of the time medical directors reported difficult access for uninsured patients, 4% for insured patients, and 6% for Medicaid

• Hospital admissions: 33% uninsured, 7% insured, 11% Medicaid

• Mental health services: 42% uninsured, 10% insured, 21% Medicaid

• Substance abuse services: 52% uninsured, 18% insured, 30% Medicaid

The authors suggest two ways that new policies might improve this situation.

First, the federal government could provide additional resources for outside services that require up-front payment. Paying up-front is a major barrier for the uninsured, many of whom are low income, says Cook. Earmarking additional funds for this would really help alleviate this particular obstacle.

Second, policy makers should encourage affiliations between CHCs and medical schools or hospitals. According to Landon, centers with such affili
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